Get Buy Online

This guide provides clear and comprehensive instructions on how to complete the Buy Online form. Follow these steps to ensure that you fill out the form accurately and efficiently.

Follow the steps to successfully complete the Buy Online form.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin with the Patient Information section. Enter your first name, middle initial, and last name. Specify your sex by selecting either Male or Female. Fill in your address details including street address, city, state, and zip code.
3. Provide your date of birth in the format MM/DD/YYYY. Include your email address, home or cell phone number, and work phone number, indicating the best time to contact you.
4. Complete the Insurance Information section. Provide details about your primary and secondary insurance. Include cardholder names, their relationship to you, employer information, and insurance company phone numbers.
5. In the Preferred Site of Injection section, select the appropriate option such as Prescriber Office, Pharmacy Benefit, Medical Benefit, or Patient Self-injection. Ensure to check at least one box.
6. Fill out the Patient Authorization section by signing and dating the form to permit the release of your protected health information.
7. If applicable, complete the StelaraSupport™ Extended Services Enrollment section by checking the desired optional services and signing it.
8. In the Prescriber Information section, provide the prescriber’s name, specialty, practice name, and contact details.
9. Complete the Clinical Information section with relevant diagnosis codes and comments, as well as any prior medications taken.
10. If requesting benefits investigation, complete the Prescription Information section including medication details and shipping address.
11. Finally, review the completed form for accuracy. Once confirmed, you can choose to save changes, download, print, or share the form as needed.

Complete your documents online with confidence by following these steps.