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Click ‘Get Form’ to open it in the editor.
Begin by filling out the PHYSICIAN INFORMATION section. Enter the Physician Name, Specialty, and DEA, NPI or TIN. Ensure all asterisked (*) items are completed for privacy compliance.
Next, complete the PATIENT INFORMATION section. Fill in the Patient Name, Cigna ID, Date of Birth, and contact details including Phone and Address.
Indicate the urgency of the request by selecting either 'Standard' or 'Urgent'. If urgent, confirm that applying standard review time may jeopardize health.
In the Medication Requested section, select from the list of medications relevant to Multiple Sclerosis. Specify Dose and Quantity as well as Duration of therapy.
Provide details regarding previous therapies under Clinical Information. Check any applicable drugs and document responses or intolerances experienced.
Finally, review all entered information for accuracy before submitting your form via fax or online submission options provided.

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