Loading
Get Distribution Program
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Distribution Program online
This guide provides comprehensive instructions on how to complete the Distribution Program registration form online. It aims to ensure that existing patients continue to have access to the treatment.
Follow the steps to successfully register for the Distribution Program
- Click the ‘Get Form’ button to download the Distribution Program registration form. Ensure you have the most current version before proceeding.
- Complete the Patient Information section. This includes entering the patient's first and last name, address, city, state, zip code, phone number, and date of birth.
- If applicable, fill out the Patient Representative Information section. Provide the representative's first and last name, phone number, and their relationship to the patient.
- In the Prescriber Information section, enter the prescriber's first and last name, facility name, NPI number, address, city, state, zip code, and fax number.
- If the infusing healthcare provider is different from the prescriber, complete the Infusing Healthcare Provider Information section with the necessary details.
- Fill out the Treatment Information section to indicate the patient's therapy status as either new to therapy or an existing patient on therapy. Optionally, provide the start date if the patient is an existing patient.
- Sign and date the Healthcare Provider Signature section to certify the accuracy of the information provided.
- Once all sections of the form are completed, fax the registration form to 1-855-782-1233.
- Wait for a confirmation fax within 24 hours, which will include a unique patient identification number necessary for ordering .
- Retain the unique patient identification number and ensure it is provided to the infusing healthcare provider if you are not the one currently infusing the patient.
- If notified of any incomplete enrollment requests, promptly provide the requested additional information for processing.
Complete your registration forms online today to ensure continued access to treatment for your patients.
Related links form
A file distributor is an entity or tool that helps manage and distribute files efficiently. This can include organizing documents for easy access and sharing them with relevant parties. If you're using a Distribution Program, it may include features that simplify file distribution, enhancing your productivity.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.