Get Onychomycosisfaxforms0812. Image - Dhhs Nh

This guide provides a clear and concise overview of how to properly complete the Onychomycosisfaxforms0812. Image - Dhhs Nh. Whether you are a healthcare professional or working on behalf of a patient, this step-by-step approach will assist you in navigating the form effectively.

Follow the steps to fill out the form accurately.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter the patient’s information, including their full name, Medicaid number, date of birth, gender, drug name, strength, dosing directions, and length of therapy.
3. Proceed to Section II to provide the clinical history, including the patient’s diagnosis and any relevant laboratory tests or procedures. List the findings and dates in the appropriate fields.
4. Indicate whether the patient has immunosuppression, diabetes, or peripheral vascular compromise by selecting 'Yes' or 'No,' and specify the diagnosis if applicable.
5. Address whether the patient is experiencing pain that limits normal activities, again selecting 'Yes' or 'No.'
6. Utilize provided space to share any additional information that may be helpful for decision-making. If necessary, attach an extra page.
7. If requesting a non-preferred product, advance to Section III. Otherwise, move to Section IV.
8. In Section III, fulfill the non-preferred drug approval criteria by detailing allergic reactions, drug interactions, previous episodes of side effects, contraindications, age-specific indications, unique clinical indications, and clinical risks associated with changing therapy.
9. Complete Section IV by providing prescriber information, such as name, NPI number, phone number, and fax number.
10. Finally, certify the accuracy of the information by signing the form as the prescribing provider. Ensure all sections are completed accurately.
11. Once you have filled out the form, save your changes and proceed to download, print, or share the completed document as needed.

Complete your documents online with confidence today.