Get the free Synagis Reorder Form

AetnaSpecialtyPharmacy. com Reorder Form This is not a prescription Dear Doctor Please complete the form below and fax back to Aetna Specialty Pharmacy at 1-860-907-3861. STEP 2 Indicate Necessary Supplies Needle 25G 5/8 qty Needle 30G 1/2 qty Syringe 3ml qty STEP 3 Select Delivery Location Physician s Office address on file Home Health Agency address on file Patient s Home address on file Other Therapy is complete STEP 4 Fax the complete...

How to fill out synagis reorder form

How to fill out Synagis Reorder Form

1. Obtain the Synagis Reorder Form from your healthcare provider or pharmacy.
2. Fill in the patient's information, including name, date of birth, and medical record number.
3. Provide the prescribing physician's details, including their name, contact information, and NPI number.
4. Indicate the specific dosage and number of vials required for the patient.
5. Select the preferred delivery date and method (e.g., shipping address).
6. Review the form for completeness and accuracy.
7. Sign and date the form where indicated.
8. Submit the completed form to the specified pharmacy or healthcare provider.

Who needs Synagis Reorder Form?

1. Infants and children at high risk of severe RSV infection.
2. Patients with certain underlying health conditions, such as congenital heart disease or chronic lung disease.

People Also Ask about

How to order synagis?

Synagis® order form To order now for next dose based on an estimated weight at time of injection, please fill out the information below and fax to 1-866-391-1890.

How to bill for Synagis injection?

Providers administering Synagis® in an office or outpatient setting must use Current Procedural Terminology (CPT) code 90378 and National Drug Codes (NDC) 60574411401 (50 MG/0.5ML vial) on the Professional Claim submittal via the Provider Web Portal or when submitting an 837 Professional (837P) electronic transaction.

How much does a Synagis injection cost?

abbive Synagis Palivizumab 50mg Injection at ₹ 12000/vial in New Delhi | ID: 26510263497.

What is the fax number for Synagis?

Fax completed prior authorization request form to 855-799-2553 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts.

How do you qualify for Synagis?

SYNAGIS gives babies who are born prematurely (at or before 35 weeks, and who are 6 months of age or less at the beginning of RSV season) the virus-blocking antibodies they lack, helping protect their vulnerable lungs from RSV.

How much does Synagis cost in the US?

The cost for Synagis (100 mg/mL) intramuscular solution is around $1,910 for a supply of 0.5 milliliters, depending on the pharmacy you visit. Quoted prices are for cash-paying customers and are not valid with insurance plans.

For pdfFiller’s FAQs

What is Synagis Reorder Form?

The Synagis Reorder Form is a document used by healthcare providers to request the reordering of Synagis, a medication used to prevent serious respiratory syncytial virus (RSV) infections in high-risk infants and children.

Who is required to file Synagis Reorder Form?

Healthcare providers who are administering Synagis to eligible patients are required to file the Synagis Reorder Form to ensure that they receive the appropriate quantity of the medication for their patients.

How to fill out Synagis Reorder Form?

To fill out the Synagis Reorder Form, healthcare providers must provide patient information, the prescribed dosage, the quantity needed, and any relevant patient eligibility details. It is important to fill the form accurately to ensure timely medication delivery.

What is the purpose of Synagis Reorder Form?

The purpose of the Synagis Reorder Form is to streamline the process of ordering Synagis medication, ensuring that healthcare providers can efficiently manage the inventory required to treat high-risk patients.

What information must be reported on Synagis Reorder Form?

The information that must be reported on the Synagis Reorder Form includes patient details (such as name and date of birth), the prescribing physician's information, the dosage prescribed, the number of doses requested, and the patient's eligibility for Synagis treatment.