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Get Continuity Program P.o. Box 373 ... - Rxhope
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How to fill out the CONTINUITY PROGRAM P.O. Box 373 ... - RxHope online
Filling out the CONTINUITY PROGRAM application is a crucial step in accessing the assistance you need. This comprehensive guide will walk you through the process of completing the application step by step, ensuring that you provide all necessary information accurately.
Follow the steps to successfully complete your application.
- Begin by locating and using the ‘Get Form’ button to obtain the application form, which you can open in your preferred digital format.
- Carefully read through the introduction and instructions provided at the top of the form to ensure you understand the requirements for completion.
- Fill out the ‘Patient Information’ section with all necessary details including the patient's name, contact number, address, and date of birth. Ensure that the information is accurate and complete.
- In the ‘Diagnosis Information’ section, provide the primary and secondary diagnosis codes along with their descriptions as required.
- Complete the ‘Insurance Information’ section, entering the details of any insurance the patient may have. If you are submitting copies of insurance cards, you may skip filling out this section.
- Make sure the ‘Patient Statement’ section is signed by the patient, confirming the accuracy of the information provided.
- Next, fill out the ‘Licensed Prescriber Information’ section, listing the prescriber’s details, including name, contact number, and professional designation. Ensure this section is complete.
- The ‘Licensed Prescriber Statement’ section must be signed by the prescriber, certifying the information provided is accurate and confirming that the patient has no prescription insurance coverage for .
- Review the entire application for accuracy, ensuring all required fields are completed before finalizing.
- Once completed, you can save changes, download, print, or share the form as needed. Finally, submit the application via mail to P.O. Box 373, Somerville, NJ 08876 or fax it to (866) 217-7178.
Complete your CONTINUITY PROGRAM application online today to access the assistance you need.
Income limits for programs like Prescription Hope may vary based on several eligibility criteria. The CONTINUITY PROGRAM P.O. Box 373 ... - RxHope typically considers household income and size when determining eligibility. It’s best to contact Prescription Hope directly for specific details related to your situation.
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