Get Acariahealth Pulmonary Arterial Hypertenstion Referral Form 2020-2025

Filling out the AcariaHealth Pulmonary Arterial Hypertension Referral Form online is a straightforward process that ensures all necessary details are accurately provided. This guide is designed to assist users through each section of the form with clear instructions and supportive guidance.

Follow the steps to successfully complete the referral form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin with the patient information section. Enter the patient's name, date of birth, sex, weight (select whether in pounds or kilograms), and social security number. Include the patient's phone number, any known allergies, and full address details such as city, state, and zip code. Don’t forget to provide an emergency contact name and phone number.
3. In the prescriber information section, provide the prescriber's name, NPI (National Provider Identifier), DEA (Drug Enforcement Administration) number, and state license number. Include the supervising physician’s name, practice name, and the complete address and contact information for the practice.
4. Fill out the diagnosis information and medical assessment section. Include the primary diagnosis along with its ICD-10 code. Indicate whether the patient has been treated previously and list any medications the patient has taken or is currently taking, specifying whether they will stop those before starting new therapy.
5. In the insurance information section, attach photocopies of the front and back of the patient's insurance card (both medical and prescription).
6. If applicable, check the box for copay card enrollment and provide the copay ID.
7. Provide detailed prescription information for each medication prescribed. Specify the quantity and number of refills for each medication selected.
8. The prescriber must sign and date the form. Ensure that the signature is original, as stamped signatures will not be accepted. If required by law, send the prescription electronically or on an official state prescription blank.
9. Once all sections have been completed, review the information for accuracy. Users can then save changes, download a copy, print the form, or share it as necessary.

Complete your documents online today to ensure timely processing and submission.