Reference List for GSK Vaccines Coding - GSK Source 2026

1. Click ‘Get Form’ to open the Reference List for GSK Vaccines Coding - GSK Source in our editor.
2. Begin by filling out the 'Product Information' section. Enter the Vaccine Name, NDC (if available), CPT Code, and ICD-10 Code accurately.
3. Proceed to the 'Physician Information' section. Input details such as Physician Name, Practice Name, Street Address, City, Phone, E-mail, Fax, NPI, State, ZIP, Office Contact, PTAN (Medicare Only), and Tax ID.
4. Next, complete the 'Patient Information' section. Provide the First and Last Name of the patient along with their Phone number, Date of Birth, Street Address, City, State, and ZIP code. Indicate gender by selecting Male or Female.
5. In the 'Insurance Information' section, enter details about the Primary Medical Insurance or Medicare Part D Plan. Attach copies of both sides of the patient insurance cards as required.
6. Review the Application Checklist to ensure all necessary sections are completed and signed. Remember that either Section 1 (Patient Signature) or Section 2 (HCP/Covered Entity Authorized Representative signature) must be signed.
7. Finally, fax both pages of the completed form to GSK Vaccines Reimbursement Support Center at 877-683-1329 and call 855-636-8291 if you have any questions.

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