Follow the steps to complete the Nebulizer Request Form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the member's information in the designated fields. This includes the member's name, date of birth (DOB), IEHP ID number, phone number, and address.
3. Next, provide the prescriber's information including the prescriber's name, National Provider Identifier (NPI), office phone number, office fax number, and office address.
4. Indicate your pharmacy preference by selecting either the in-network pharmacy or in-network mail order pharmacy option.
5. For the nebulizer request section, choose one of the available nebulizer devices by marking the corresponding box. Be sure to include the required National Drug Code (NDC) numbers.
6. If applicable, fill out the medication starter pack options for the nebulizer device, including any specific medications you have been prescribed, the quantity, and the sig (instructions for use). Be sure to note the refill options as well.
7. Complete the nebulizer accessories section if additional items are required, specifying the quantity and any necessary refills.
8. Finally, ensure that the prescriber signs the form and adds the date where indicated.
9. After completing the form, review all entered information for accuracy. You can then save changes, download, print, or share the completed form as needed.

Take the next step by completing your form online today.