Get Solesta Enrollment Form

The Solesta Enrollment Form is an essential document for patients seeking treatment and support services. Completing this form online can streamline the process, ensuring your information is submitted accurately and efficiently.

Follow the steps to fill out the Solesta Enrollment Form online:

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Begin by entering your patient information. Fill in your last name, first name, middle initial, and date of birth in the designated fields.
3. Provide your complete address, including city, state, zip code, and telephone number. Make sure to include your Social Security Number and the name and phone number of a contact person.
4. In the treating provider section, enter the name and site of your prescriber, along with their specialty and contact information.
5. Next, include your insurance company details, starting with the primary insurance. Fill in the company name, phone number, member ID, group number, and the insured's name and relationship to you.
6. Indicate any previous treatments tried and failed by checking the appropriate boxes. This information can provide context for your current treatment approach.
7. For prescription information, your prescriber must fill out the necessary details. Ensure that the prescription is accurately documented and that the prescriber’s signature is included.
8. Finally, review all the information for accuracy. Once you have confirmed that everything is correct, you can save changes, download the completed form, and print or share it as needed.

Complete your Solesta Enrollment Form online today to ensure a seamless enrollment process.