Get Kroger Specialty Pharmacy Urology Referral Form 2018

Filling out the Kroger Specialty Pharmacy Urology Referral Form online can streamline the process of obtaining necessary prescriptions and patient information. This guide provides clear, step-by-step instructions to ensure users can complete the form accurately and efficiently.

Follow the steps to successfully complete the online urology referral form.

1. Click the ‘Get Form’ button to access the Kroger Specialty Pharmacy Urology Referral Form and open it in your editing interface.
2. Fill in the date on the form along with the 'needs by' date. Indicate the shipping address by selecting whether it is for the patient, an office, or another address and provide the necessary details.
3. In the patient information section, enter the patient's name, address, city, state, zip code, and contact numbers. Include the social security number and date of birth, and indicate the patient's gender.
4. In the prescriber information section, fill out the prescriber's name, address, city, state, zip code, phone number, DEA number, NPI number, and license number.
5. Check off the required documentation to fax, including the prescription card, clinical notes, and medical card, ensuring that a copy of each is prepared.
6. In the clinical information section, provide the diagnosis, the ICD-10 code, the serum PSA level, and the date this was obtained. Also, enter the patient's height and weight.
7. List any known drug allergies and prior medications that have failed, including the duration of treatment and reasons for discontinuation.
8. Indicate whether the prostate cancer is metastatic and if it is castration-resistant by selecting yes or no.
9. In the prescription information section, fill out the required fields for medication quantities and refills based on the prescribed medications. Be sure to note specific instructions for each medication.
10. Review all fields for accuracy. Once all information is filled out and verified, you may have the option to save changes, download, print, or share the form as needed.

Complete your Kroger Specialty Pharmacy Urology Referral Form online today for a seamless medication process.