Get Jazz Cares For Vyxeos Enrollment And Patient Authorization Form

This guide provides users with a clear and comprehensive overview of how to effectively fill out the Jazz Cares For Vyxeos Enrollment And Patient Authorization Form online. By following these steps, users can ensure that all necessary information is accurately submitted to participate in the Jazz Cares Program.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the Jazz Cares For Vyxeos Enrollment And Patient Authorization Form in an online editor.
2. Begin by entering the patient’s information. Fill in the patient’s name, date of birth, and contact details, including cell phone, home phone, email address, and residential address. Make sure to indicate the preferred language for communication.
3. In the Diagnosis & Clinical Information section, indicate the patient’s diagnosis by selecting the relevant ICD-10 code. Confirm whether the patient has newly diagnosed acute myeloid leukemia (t-AML) or acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) and provide the corresponding ICD-10 description.
4. Complete the Treatment Information section by specifying whether the patient is currently taking VYXEOS. Fill in the product requested, dosage, and treatment dates.
5. In the Insurance Information section, make sure to include copies of the patient’s insurance cards (front and back). Provide details of the primary and secondary insurance, including policy IDs, group numbers, and subscriber names if applicable.
6. Enter information about the physician. This includes the physician’s name, specialty, practice name, and contact information. Ensure that the physician’s signature is provided, confirming the medical necessity of the prescribed therapy.
7. If applicable, document other drugs prescribed alongside VYXEOS and confirm if the doctor is contracted with the patient’s insurance.
8. Complete the Patient Authorization section on the back of the form. The patient must sign this section to participate in the Jazz Cares Program, authorizing the disclosure of personal health information (PHI).
9. Review all entered information for accuracy and completeness. Once satisfied, users can save changes, download, print, or share the completed form as needed.

Take the next step in accessing care by completing the Jazz Cares For Vyxeos Enrollment And Patient Authorization Form online today.