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How to use or fill out The form must be completed by the prescriber and with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by entering the member’s name as it appears on their MCO Plan card in Item 1.
- In Item 2, input the member’s MCO ID number, which can be found next to their name on the card.
- For Item 3, provide the member’s date of birth and age. If applicable, include weeks of gestation for premature infants.
- Complete Item 4 by indicating the primary language of the member or family, which may require translation services.
- Fill in Item 5 with the member’s permanent address and contact number.
- In Item 6, check off the current location of the member (e.g., Home, Hospital) and provide a contact number if necessary.
- Continue filling out each section methodically, ensuring all fields are completed accurately for a smooth submission process.
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