3 Department of Vermont Health Access () PRIOR AUTHORIZATION REQUEST () - Prior Authorization/Prescription/Patient Enrollment Form Patient Diagnosis: Complete form in its entirety and fax to number.
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How to fill out the Enrollment Form online
Filling out the Enrollment Form online is a straightforward process that requires careful attention to detail. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.
Follow the steps to complete the Enrollment Form online
- Click the ‘Get Form’ button to acquire the Enrollment Form and open it within your preferred online document platform.
- In the Patient Information section, fill out all requested details such as last name, first name, middle initial, date of birth, and sex. Ensure accuracy in providing the Medicaid ID number and your current address, including street, city, state, county, and zip code.
- Provide your contact information by entering your home phone, cell phone, and any relevant parent or guardian contact, including their day and night telephone numbers. Additionally, include an emergency contact's name, relationship to you, and their telephone number.
- Indicate the patient diagnosis, specifically noting if it is 'Relapsing Multiple Sclerosis.' State any previously tried self-injectable medications that have failed, including dates and reasons for discontinuation.
- Complete the Prescriber Information section with the prescriber's name, NPI number, and contact information, including their telephone and fax numbers. Also, include the hospital or clinic name and address.
- Specify the prescription details by entering the requested dispense quantity and sig, which in this case is to take one capsule once daily. Indicate the number of refills if applicable.
- The prescriber must sign and date the form in the designated field, and if there are additional comments from the prescriber, summarize them as needed.
- Upon completion of the form, save any changes made. Then, ensure all information is correct before downloading, printing, or sharing the Enrollment Form as required. Fax the completed form to the number listed below.
Begin filling out the Enrollment Form online today to ensure timely processing of your request.
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