Maryland physicians care form 2025

1. Click ‘Get Form’ to open it in our editor.
2. Begin by entering the Patient Name, Prescriber Name, Member ID #, and Prescriber NPI# in the designated fields. Ensure accuracy to avoid delays.
3. Fill in the Tax ID Number, Office Phone, and Office Fax. Indicate the patient's sex by circling 'M' or 'F', and provide their Height and Weight.
4. Enter the Date of Birth (DOB) and any known Allergies. If applicable, include details for the Servicing Provider and their NPI#.
5. Specify the Medication, Strength & Dose along with the Route of Administration. Indicate whether this is a New Therapy or Continuation by checking the appropriate box.
6. Provide Diagnosis for Medication Treatment, Directions, Expected Length of Therapy, and ICD10 Code as required.
7. Ensure that you sign in the PRESCRIBER’S SIGNATURE section and include the HCPCS/J Code along with the date.
8. Select how the medication will be obtained (medical benefit or pharmacy benefit) and fill in any additional required information regarding rationale for exception requests.

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