Get Wakix Prescription Referral Form

Filling out the Wakix Prescription Referral Form online can streamline the process of obtaining necessary medication. This guide provides step-by-step instructions to ensure that users can complete the form accurately and efficiently.

Follow the steps to successfully complete the Wakix Prescription Referral Form.

1. Press the ‘Get Form’ button to access the Wakix Prescription Referral Form and open it in your preferred document editor.
2. Begin by filling out the patient information section which includes fields for the first name, middle initial, last name, date of birth, and address. Ensure all information is accurate to prevent delays.
3. Provide the last four digits of the social security number and complete the contact information sections, including primary and mobile phone numbers, as well as preferred language and email address.
4. In the patient insurance information section, indicate whether the patient has insurance. If so, fill out the relevant fields, including the policyholder’s name, insurer information, and policy details.
5. Complete the prescriber information section by entering the prescriber’s first and last name, office details, and contact information.
6. In the diagnosis section, select the appropriate ICD-10 code for narcolepsy or specify another diagnosis if applicable.
7. Fill out the Wakix prescription information section, choosing between titration and maintenance prescriptions, and specify dosages as needed. Ensure to indicate the number of refills.
8. The prescriber must sign the authorization section, certifying the information's accuracy and giving consent for sharing necessary health information.
9. Obtain patient consent by having the patient sign the Patient Services Authorization and Marketing Authorization sections to permit sharing of their health information.
10. Once all fields have been completed, review the form for accuracy. Users can then save changes, download, print, or share the completed form as required.

Take action now to fill out the Wakix Prescription Referral Form online and ensure effective medication management.