Virus enrollment 2026

1. Click ‘Get Form’ to open the virus enrollment form in the editor.
2. Begin by filling out SECTION I, which includes member and provider information. Enter the member's name, identification number, date of birth, prescriber details, and billing provider information.
3. Move to SECTION II for clinical information. Indicate if Synagis® was administered during hospitalization and provide the relevant dates. Record the child's current weight and date weighed, then calculate the dosage based on their weight.
4. In SECTION III, select the appropriate clinical information based on the child's condition. Complete one subsection (A-F) that applies to their medical history.
5. Finalize your submission by signing in SECTION IV and providing any additional information in SECTION V that may support your request.

Start using our platform today to streamline your virus enrollment process for free!