Get Patient Enrollment Form Solesta Reimbursement Helpline

Completing the Patient Enrollment Form for the Solesta Reimbursement Helpline online is a straightforward process. This guide provides step-by-step instructions to ensure that you provide all necessary information accurately.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Patient Enrollment Form.
2. Begin by entering the patient information. Fill in the name, date of birth, gender, address, city, state, zip code, home phone number, alternate phone number, email address, and social security number.
3. Proceed to the insurance information section. Enter the details for the primary and secondary insurance, including the insured name/relationship, policy ID, and group number. Additionally, if available, provide a copy of the patient’s insurance cards.
4. In the medical assessment section, specify the primary diagnosis and any prior treatment history. Indicate whether the patient has previously been treated with Solesta and the date of the last treatment. List any prior therapies that have been attempted.
5. Provide prescriber information, including the prescriber’s name, specialty, facility name, phone, fax, address, office contact name/title, NPI, tax ID, Medicaid provider number, PTAN, DEA, and license number.
6. If the site of care differs from the prescriber’s office, provide the facility name and phone number in the respective section.
7. In the services requested section, specify if the Solesta will be administered in the office or through a specialty pharmacy. Indicate whether Medicare claims tracking assistance is needed.
8. Fill out the prescription information for the Solesta kit, indicating the quantity and any specific shipping instructions.
9. Ensure the prescriber’s certification section is completed by obtaining the prescriber’s signature and the date of signing.
10. Once all required fields have been filled out, save the changes. You can then download, print, or share the completed form as needed.

Start filling out the Patient Enrollment Form online to ensure a smooth reimbursement process.