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- Click ‘Get Form’ to open the Fax: 1-877-378-4727 document in the editor.
- Begin by filling out the Cardholder and Patient Information section. Enter the cardholder's name, patient’s name, address, date of birth, and sex. Ensure all fields are completed accurately.
- Proceed to the Physician Completes section. The physician must answer questions regarding the patient's diagnosis and treatment history. Make sure to check 'Yes' or 'No' where applicable and provide any necessary details.
- Complete the prescriber certification at the bottom of the form. The physician should print their name, provide contact information, and sign the document to validate it.
- Once all sections are filled out correctly, save your changes. You can then fax the completed form to 1-877-378-4727 directly from our platform for convenience.
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