Get Sir-spheres 523-u-0312 2012-2025

Filling out the SIR-Spheres 523-U-0312 form online can be a straightforward process when you have clear guidance. This document allows for the predetermination of medical necessity and coverage restrictions prior to treatment.

Follow the steps to complete the SIR-Spheres 523-U-0312 form accurately.

1. Click ‘Get Form’ button to access the form and launch it in your online editor.
2. Enter the treating center information. This includes the hospital or center name, address, city, state, ZIP code, tax ID or NPI number, and phone. Ensure all fields are filled correctly.
3. Provide the patient information. Fill in the patient’s name, address, city, state, ZIP code, date of birth, social security number, and contact details, including email and phone.
4. Indicate the permission for Sirtex to contact the patient if necessary by selecting ‘Yes’ or ‘No’. Also, specify the sex of the patient.
5. Fill in the administering provider information, including the physician's name and contact details. Include the physician's tax ID number and NPI number as applicable.
6. Provide detailed treatment information. Include the primary and secondary diagnosis (ICD-9 codes and descriptions), as well as the estimated treatment dates for the right and left lobes, if applicable.
7. Input the patient’s primary and secondary insurance information, including the insurance name, policy number, group number, relationship to insured, and any other relevant details.
8. Fill in any additional coding information required, and check the appropriate codes for pre-treatment evaluations and treatments.
9. Review all entered information for accuracy. Make any necessary edits to ensure completeness.
10. Once completed, save your changes, and you may choose to download, print, or share the form as required.

Start completing your SIR-Spheres 523-U-0312 form online today.