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Get Customer Care Program Enrolment Form - Lillypro.ca
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How to fill out the CUSTOMER CARE PROGRAM ENROLMENT FORM - Lillypro.ca online
Filling out the CUSTOMER CARE PROGRAM ENROLMENT FORM is an essential step for individuals seeking to participate in the Customer Care Program. This guide will provide you with clear, step-by-step instructions to assist you in submitting the form efficiently and accurately online.
Follow the steps to complete the online form successfully.
- Press the ‘Get Form’ button to access and open the CUSTOMER CARE PROGRAM ENROLMENT FORM.
- Begin by filling out the prescription details. Indicate the medication and the prescribed dosage, along with the diagnosis. Ensure you select the appropriate diagnosis option that reflects the patient's condition.
- Locate the physician authorization section. The prescribing physician must provide their signature, license number, and date. Ensure that verbal consent is indicated if applicable.
- Proceed to the provincial coverage section. Indicate whether this will be submitted to a provincial drug coverage plan by checking 'Yes' or 'No'.
- Fill in the referral section if applicable. Include the name of the referring physician if they are an orthopedic surgeon, GP, or family physician.
- In the patient information section, provide the patient's first name, last name, date of birth, address, health card number, city, province, preferred telephone number, and optional email address.
- Indicate the patient's gender by checking the corresponding box for 'M' or 'F'. Complete the postal code field.
- Read the patient consent and privacy information carefully. Acknowledge by signing and dating the document. Ensure that the person providing the signature is the patient or their legal representative.
- Once all fields are completed accurately, save your changes. You will have the option to download, print, or share the completed form as needed.
Complete your form online today to ensure your participation in the CUSTOMER CARE PROGRAM.
Eli Lilly does have a dedicated patient assistance program for Mounjaro. This program helps qualified patients gain access to the medication regardless of their financial situation. More details on how to apply are available through the CUSTOMER CARE PROGRAM ENROLMENT FORM - Lillypro.ca.