How to use or fill out Fillable Online Policy Name Fees Policy Department Finance
- Click ‘Get Form’ to open it in the editor.
- Begin with Section I – Member Information. Enter the member's name, ID number, and date of birth clearly.
- Proceed to Section II – Prescription Information. Fill in the date the prescription was written, prescriber's name, National Provider Identifier, address, and telephone number.
- Indicate the proposed hepatitis C drug treatment regimen by entering drug names, whether currently taking them, daily doses, and expected duration.
- In Section III – Clinical Information, provide diagnosis codes and descriptions. Ensure to include required medical records as specified.
- Complete any additional sections as necessary based on the member's history and treatment details before signing in Section IV.
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