 
                Get Daiichi Sankyo Open Care Program Form
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How to fill out the Daiichi Sankyo Open Care Program Form online
Filling out the Daiichi Sankyo Open Care Program Form online can streamline your application process and help you receive the necessary assistance efficiently. This guide provides step-by-step instructions to ensure you complete each section accurately.
Follow the steps to successfully fill out the form.
- Press the ‘Get Form’ button to access the form in your browser and begin the application process.
- Complete the Patient Information Section, providing details such as name, social security number, mailing address, date of birth, and phone number. Ensure all information is accurate and clearly written.
- In the Eligibility Section, answer the questions regarding the patient's legal U.S. residency status, Medicare Part D enrollment, and any other prescription coverage. Indicate the yearly household income and the number of individuals living in the household.
- Sign the Patient Certification and Authorization to Disclose Information section. This confirms that the information provided is accurate and grants permission to process your request.
- Fill out the Licensed Practitioner Section, which requires the practitioner's name, contact information, and DEA number (or a copy of the current state license if a DEA number is unavailable).
- In the Prescription Information Section, list the name, strength, and quantity for each product prescribed, and request the appropriate number of refills.
- Obtain the required signatures from both the patient and the licensed practitioner to validate the application.
- Save your changes to the completed form. You can then download, print, or share the document as needed.
- Finally, send the completed application, prescription, and proof of household income via fax or mail to the addresses provided.
Start filling out your document online today to ensure timely submission for the Daiichi Sankyo Open Care Program.
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