Get Endo Prescription And Benefits Investigation Form 2024-2025

The Endo Prescription And Benefits Investigation Form is a vital document for managing prescriptions and insurance benefits effectively. This guide aims to provide clear and step-by-step instructions for completing the form online, ensuring timely processing and proper communication with healthcare providers.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering your personal information in the designated fields, including first name, last name, middle initial, address, city, state, ZIP code, mobile phone number, last four digits of SSN, email, and date of birth.
3. Provide details regarding your primary insurance, including policy number, group number, and provider services phone number. If you have secondary insurance, repeat this step for the second insurance provider.
4. Fill out the physician's information, including their name, specialty, practice name, and complete ship-to address, along with contact phone number, fax number, NPI number, DEA number, tax ID number, and Medicare PTAN.
5. If applicable, indicate your ® REMS healthcare provider enrollment ID and setting enrollment ID. You should also provide a contact person's name and email.
6. Complete the clinical information section by providing relevant details such as diagnosis code, presence of palpable plaque, degree of penile curvature, prior treatments for Peyronie’s disease, medication allergies, and anticipated injection date.
7. In the authorization sections, confirm your consent to share health information and opt-in for text message notifications from CVS Specialty Pharmacy. Ensure you read and understand all terms before signing.
8. A prescriber signature is required in two places. Ensure you have both signatures (no stamps) and the corresponding dates filled out.
9. Before finalizing your form, review all the entered information for accuracy. Then, attach any necessary clinical notes and supporting documentation required.
10. Once you have completed the form and attached necessary documents, save your changes. You can also choose to download, print, or share the form as needed.

Take action now by completing the Endo Prescription And Benefits Investigation Form online.