Get Theraskin 52-tsbvr.0

Filling out the TheraSkin 52-TSBVR.0 form online can streamline the process of verifying patient eligibility and insurance coverage. This guide provides detailed, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the TheraSkin 52-TSBVR.0 form.

1. Click ‘Get Form’ button to obtain the TheraSkin 52-TSBVR.0 and open it in your preferred online editor.
2. Begin by providing the patient's demographic information. Fill in the patient's name, address, phone number, and date of birth. Ensure that the Social Security number is not included for Massachusetts residents.
3. Input the patient wound information. Select the wound type from the provided options and indicate if prior authorization or pre-determination is required. If yes, remember to attach the patient's clinical records.
4. Include the product HCPCS code (Q4121) and the date of the TheraSkin application. Specify the anticipated number of applications.
5. Provide the appropriate application CPT codes and ICD-9 diagnosis codes. Make sure to include primary and secondary diagnosis codes as needed.
6. Fill in the patient's insurance information. This includes both primary and secondary insurance details, participating status, policy number, and subscriber information. If possible, attach a copy of the patient’s insurance card.
7. Enter the physician's information, including place of service and physician specialty. Ensure you specify if the site bills to Medicare Part A or Part B.
8. Complete the facility information with accurate details regarding the facility name, address, and tax identification number.
9. Finally, include the physician declaration. The physician must sign and date the form to certify that they have obtained patient authorization to release the necessary information.
10. Once completed, review the form for accuracy. You can then save your changes, download the document, print a copy, or share it with the necessary parties.

Complete your documents online to ensure timely processing of your TheraSkin 52-TSBVR.0 form.