EVZIO Intake Form - AllCare Plus Pharmacy 2025

1. Click ‘Get Form’ to open the EVZIO Intake Form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, address, city, state, zip code, phone number, social security number, date of birth, and gender.
3. Next, complete the 'Facility Information' if applicable. Provide the facility name and contact details.
4. In the 'Insurance' section, ensure to fax a copy of both the prescription card and medical card (front and back) as required.
5. Proceed to 'Clinical Information'. Input the diagnosis using ICD-10 codes. Include any additional information relevant to the patient's condition.
6. Fill out the 'Prescription Information' section by specifying drug details such as dosage/strength and directions for use. Indicate quantity and refills needed.
7. Finally, have a physician sign and date the form at the bottom to authorize processing.

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