Get Pp-in-us-0139 2018-2026

The PP-IN-US-0139 form is essential for patients seeking assistance with ® or Injectafer®. This guide provides clear instructions to help users accurately complete the online application.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Enter the requested product by selecting either ® or Injectafer® in the designated field.
3. Fill in the patient information section, including the patient’s name, case number, social security number, sex, date of birth, address, city, state, zip code, and daytime and evening phone numbers.
4. Specify the primary and secondary diagnosis related to the patient's treatment.
5. Indicate if the patient is currently receiving dialysis treatment by selecting 'Yes' or 'No'.
6. Complete the provider information section by providing the physician’s name, contact person, facility or practice name, address, city, state, daytime phone number, zip code, and fax number.
7. In the insurance information section, provide details about the patient’s health insurance coverage, marking each applicable insurer status such as Medicare, Medicaid, or private. Indicate the insurer’s plan name and effective date.
8. Input the total annual household income from the most recent federal tax return and the number of individuals in the household.
9. Review the patient certification and consent section. Ensure that the patient’s signature and date are added, confirming they understand the terms.
10. Fill out the provider certification statement, ensuring the provider’s signature and date are included, confirming medical necessity and consent.
11. Once all sections are completed, save changes, download, print, or share the form as needed.

Complete your application today by filling out the PP-IN-US-0139 online.