Get Daiichi Sankyo Open Care Program P.o. Box 8409 Somerville, Nj ...

Navigating the Daiichi Sankyo Open Care Program application can be straightforward with the right guidance. This guide provides step-by-step instructions on how to fill out the application accurately to ensure a smooth submission process.

Follow the steps to complete the application form effectively.

1. Click the ‘Get Form’ button to obtain the application form and open it for completion.
2. Begin by filling out the Patient Information section. Provide the patient's name, social security number, mailing address, date of birth, city, state, zip code, and phone number. Ensure all information is accurate and legible.
3. In the Eligibility section, answer the questions regarding legal residency, Medicare Part D enrollment, and government or private prescription coverage. Select 'YES' or 'NO' as applicable.
4. Next, indicate the yearly household income and the number of people living in the household. Include all sources of income for accuracy.
5. Confirm the Patient Certification and Authorization to Disclose Information by signing the provided section, ensuring that the patient's understanding of terms is clear.
6. Proceed to the Licensed Practitioner Section. The licensed practitioner should fill out their name, phone number, and office address (use only the street address). Ensure the form is signed without stamps.
7. Complete the Prescription Information section. The practitioner must provide details about the medications, including product names, strength, quantity per day, and refills necessary for one year.
8. Finally, review the application for completeness and legibility. Fax or mail the completed application, prescription (if applicable), and proof of annual household income to the designated fax number or P.O. Box 8409 Somerville, NJ 08876. Ensure you keep copies for your records.

Complete your Daiichi Sankyo Open Care Program application online today to ensure you receive the support you need.