866 752 7021-2026

1. Click ‘Get Form’ to open the 866 752 7021 document in the editor.
2. Begin by entering the start date of treatment and the date of the last treatment in the designated fields.
3. Fill out the Patient Information section, including first name, last name, address, phone numbers, email, date of birth, allergies, current weight, and height.
4. In the Insurance Information section, indicate if the patient has other coverage and provide necessary details such as ID numbers and carrier names.
5. Complete the Prescriber Information section with details about the prescribing physician including their name, contact information, and specialty.
6. For Dispensing Provider/Administration Information, specify where the treatment will take place and provide relevant provider details.
7. In Product Information, indicate the requested product (Lucentis) along with dosage and directions for use.
8. Fill out Diagnosis Information by providing primary ICD codes and any additional codes as applicable.
9. Complete Clinical Information by selecting appropriate diagnoses and answering questions regarding previous treatments.
10. Finally, ensure that all sections are completed before signing and dating at the end of the form.

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