Get Kevzara Enrollment Form

This guide provides a clear and supportive approach to filling out the Kevzara Enrollment Form online. By following the steps outlined below, users can ensure accurate and complete submissions for enrolling in the KevzaraConnect program.

Follow the steps to complete the Kevzara Enrollment Form online.

1. Press the ‘Get Form’ button to access the enrollment form and open it in your preferred editor.
2. Begin with Section 1 – Patient Information. Fill out your date of birth, full name, mobile phone number, street address, city, state, ZIP code, preferred language if not English, and email address. Indicate your preferred contact method for follow-ups.
3. Complete the gender field as applicable and provide an alternate phone number if desired. Review the consent statements regarding text messaging and authorization carefully before signing.
4. Proceed to Section 2 – Insurance Information. Input the details for your primary medical and prescription drug insurance, including policy ID numbers and group numbers. If applicable, attach copies of your insurance cards.
5. In Section 3 – Prescriber Information, fill out your prescriber's name, practice name, specialty, NPI number, and contact information as required.
6. For Section 4 – Clinical and Diagnosis Information, provide your primary diagnosis code, current medications, and any prior medications you've failed. Attach any clinical notes if necessary.
7. In Section 5 – Prescription Information, indicate your preferred specialty pharmacy and fill out the prescription details accurately, including dosages and quantities.
8. If you are applying for the Patient Assistance Program, complete Section 6 regarding household income and the number of individuals in your household.
9. Read and complete Sections 7 and 8 regarding patient certifications and authorizations. Ensure you understand the implications of these sections before signing.
10. After completing all sections, review your entries for accuracy. Save your changes, and download or print the form for submission. Finally, fax pages 1-4 to KevzaraConnect at 1-844-538-8960.

Ready to get started? Complete your Kevzara Enrollment Form online today.