Follow the steps to successfully fill out the Pharmacy Referral Form online.

1. To initiate the process, click the ‘Get Form’ button to access the Pharmacy Referral Form. This will allow you to view the form in your preferred digital format.
2. Enter the current date in the designated field to indicate when the referral is being made.
3. Provide a contact telephone number for the patient. This number must be included to ensure proper communication regarding the referral.
4. Fill in the patient's name, date of birth, and home address, including city, state, and ZIP code to fully identify the individual requiring the referral.
5. Input the patient’s Medicaid ID number in the relevant field to ensure that the patient’s insurance details are accurately captured.
6. Complete the HCP Group ID and HCP ID sections to identify the healthcare provider involved.
7. Document the primary diagnosis and corresponding ICD-10 code that justifies the referral for 17-alpha hydroxyprogesterone caproate.
8. Indicate the current gestational age (EGA) in weeks and the estimated date of confinement (EDC). This information is critical for proper medication administration.
9. Provide indications for 17P administration in the specified section to guide the prescribing instructions.
10. In the prescription information section, detail the medication specifics, including the dosage and administration instructions clearly.
11. Enter the date for the first administration appointment to ensure timely follow-up for the patient.
12. Fill out the prescriber information, including the doctor's name, phone number, office name, and address. Ensure to include their NPI, DEA, and state medical license numbers.
13. Lastly, provide the number of prescriptions, and indicate whether substitution is permissible or if 'dispense as written' applies.
14. Obtain the prescriber’s signature to validate the referral, noting that signature stamps are not accepted. Double-check all fields for accuracy.
15. Once completed, save changes and prepare to fax the form directly from the prescriber’s office to the designated fax number. Ensure that no patient-faxed prescriptions are submitted.

Complete your Pharmacy Referral Form online today for a streamlined process in patient care.