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01. Edit your injectable form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
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03. Share your form with others
Send injectable form blank via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out the Injectable Infusion Form
- Click ‘Get Form’ to open it in the editor.
- Begin by identifying who is making the request. Select either 'Provider', 'Member', or 'Appointed Representatives' and ensure you attach any necessary documentation.
- Choose between a Standard Review (72 hours) or an Expedited Review (24 hours) by checking the appropriate box. Remember, selecting expedited indicates urgency regarding the member's health.
- Fill in the member's details including Name, ID#, Address, Phone, Height/Weight, Allergies, Date of Birth, Diagnosis, ICD9 code, and Dose.
- Provide your information as the provider: Name, Address, Phone, Fax, Contact Name, and Provider ID/NPI.
- Indicate the Frequency of treatment and Length of Treatment required.
- Document clinical rationale for any override requests and list previous medications tried and failed.
- Answer all questions regarding the member’s care setting accurately to ensure thorough review.
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