Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your online editor.
2. Begin by entering the patient information. Include the last name, first name, address, date of birth, state, city, gender, height, home phone, weight, cell phone number, zip code, social security number, and email address. Make sure to fill in all fields completely to avoid any delays.
3. In the section labeled 'Allergies', list any known allergies. This information is crucial for medical safety.
4. Provide an emergency contact name and phone number in the designated area.
5. Complete the insurance information section by filling in the policy number, primary and secondary insurance details if applicable, along with group numbers and the policyholder's name. Attach a current copy of the insurance card if needed.
6. Next, move to the clinical information section. Enter the primary and secondary diagnosis along with their respective diagnosis codes and the date diagnosed. Also, calculate the body surface area (BSA).
7. In the medications section, indicate any medications being taken, specify the strength, and include details regarding previous treatment regimens.
8. Fill in directions for medication use, quantity, and refills needed.
9. Specify the delivery instructions by selecting the preferred delivery location for the medication.
10. Complete the physician information section accurately, including the physician’s name, NPI number, license number, state, DEA number, and contact information.
11. Finally, ensure the prescriber’s signature is obtained, as stamped signatures are not permitted. Date the form accordingly.
12. Review all filled-out information for accuracy. Once completed, save any changes made to the document, and you may choose to download or print the form for your records.

Complete your documentation online to ensure timely processing of your referral.