Get Xubex Registration Form

The Xubex Registration Form is designed to gather essential information to assist individuals in applying for Xubex’s Patient Assistance Program. Completing this form accurately will ensure that you receive the appropriate support tailored to your needs.

Follow the steps to successfully complete the Xubex Registration Form online.

1. Press the ‘Get Form’ button to access the registration form and open it in the editor.
2. Begin by filling out the patient information section. Input your first name, last name, middle initial, complete address (including city, state, and zip code), and date of birth. Indicate your gender by selecting either 'Male' or 'Female'.
3. Provide your Social Security Number (SSN), best phone number, alternate phone number, and email address in the insurance information section.
4. Next, indicate whether you have Medicare by selecting 'Yes' or 'No'. If applicable, enter your Medicare ID number and the phone number associated with it.
5. Fill in your prescription insurance company details including the BIN number, PCN number, ID number, and group number.
6. In the drug and food allergies section, select any allergies you may have by marking the corresponding boxes. Make sure to list any other allergies in the provided field.
7. Document your health conditions by checking all that apply. If applicable, list any other health conditions not specified.
8. If you are taking any medications or supplements, please list them in the designated area.
9. Provide your physician information by entering their first name, last name, phone number, alternate phone number, and fax number.
10. In the additional comments section, include any other relevant information that could help ensure your needs are met.
11. If you are transferring prescriptions to Xubex, fill out the prescription transfer information section, indicating whether you want to transfer prescriptions and providing the pharmacy's details.
12. Select your method of payment by marking the preferred option and fill in the required cardholder information.
13. Choose your shipping option from the provided list and enter your signature to authorize the necessary actions by Xubex.
14. Once you have completed all sections of the form, ensure all information is accurate. Save changes, download, or print the completed form, or share it as needed.

Take the next step toward your healthcare needs by completing the Xubex Registration Form online today.