*HPC will verify insurance benefits, initiate PAs and notify patient prior to admission of any out o 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's last name, first name, address, date of birth, gender, height, weight, and contact details including home phone and cell number.
3. In the Insurance Information section, provide details about the primary and secondary insurance policies. Include policy numbers, group numbers, and policy holder's names. Ensure you attach a current copy of the insurance card if available.
4. Complete the Clinical Information section by entering the primary and secondary diagnoses along with their respective codes and date diagnosed.
5. Fill in the Medications section by selecting applicable medications and providing strength, quantity, and refills as necessary.
6. Specify delivery instructions in the Education & Delivery Instructions section by choosing where to deliver medications.
7. Finally, complete the Physician Information section with all required details including physician's name, NPI number, license number, address, phone number, and fax number. Ensure that a physician's signature is provided at the end.

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