Statement of Medical Necessity (SMN) - Access 360 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Specialty Pharmacy Provider Name and contact details. Ensure all information is accurate for seamless communication.
3. In the Patient Information section, enter the patient's full name, date of birth, and social security number. Complete the address fields and guardian information as required.
4. Provide insurance details, including whether there is no insurance or if a copy of the medical/pharmacy card is included. Fill in primary and secondary insurance information as applicable.
5. Complete the Prescriber Information section with treating/referring provider details, including NPI and license numbers.
6. In the Diagnosis section, accurately record gestational age, current weight, and relevant ICD codes for primary and secondary diagnoses.
7. Fill out Clinical Information by checking applicable treatments received and risk factors related to the patient’s condition.
8. Lastly, complete Prescription Information regarding previous Synagis administration and delivery preferences before signing off on the form.

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