Get Ca Ssrx Nephrology Referral Form_dsa

Filling out the CA SSRx Nephrology Referral Form_DSA online is a straightforward process that ensures accurate patient information is conveyed for referral. This guide will provide you with step-by-step instructions to effectively complete each section of the form.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the form and access it in your online document editor.
2. Begin by entering the patient information. Provide the last name and first name of the patient, along with their date of birth, social security number, and weight and height details.
3. Next, input the patient's insurance information, including the primary medical insurance name, insurance phone number, subscriber name, and relevant card details such as Rx Card (PBM), group number, bin number, and PCN number.
4. Continue to fill out the treatment arrangements section by specifying the start date for the treatment and whether medications will be shipped to the patient’s home or the doctor’s office. Indicate who will provide the necessary teaching regarding the treatment.
5. In the diagnosis section, select the appropriate diagnosis option based on the patient's condition. If applicable, provide an alternative diagnosis.
6. Complete the medical assessment section by answering the questions related to iron store evaluation. Provide the dates and results for transferrin saturation and ferritin levels, and document blood pressure information.
7. Identify if the patient has been treated previously for their condition by indicating which medications failed if applicable. Specify whether the patient is currently on therapy and list any relevant medications.
8. Fill out the prescription information by selecting the required medications along with the dosage options, administration routes, and additional details for frequency and quantity.
9. Lastly, ensure the physician’s signature, name, contact information, NPI, and DEA information are provided in the designated area. Review all segments filled out for accuracy.
10. Once all the required fields are completed, save any changes made, and choose to either download, print, or share the form as needed.

Complete your documents online to ensure proper submission and processing.