Get Coloplast Care Program

The Coloplast Care Program is designed to assist individuals with intimate healthcare needs by providing valuable resources and support. This guide will walk you through the process of filling out the Coloplast Care Program Patient Enrollment Form online, ensuring that you can easily access the benefits offered.

Follow the steps to successfully complete the enrollment process.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your personal information. You will need to enter your first name, last name, address, city, state, and zip code in the designated fields.
3. Provide your contact details by entering your email address and phone number accurately.
4. Indicate the date you began catheterization. It is important to provide this information for proper program support.
5. Select your gender by choosing either 'Male' or 'Female.' If applicable, indicate the language preference from the provided options.
6. If you use intermittent catheters or male external catheters, specify the sizes in the relevant fields.
7. Provide the name of the clinic and clinician who referred you to this program, if applicable.
8. Answer the question regarding whether you have already been referred to a supplier by selecting 'Yes' or 'No,' and provide details if necessary.
9. Enter your insurance provider's name in the dedicated field.
10. Review the enrollment options. You can choose to fax the form to 1-800-501-8533, email your request to samples@coloplast.com, or call Coloplast Consumer Care at 1-888-726-7872 to enroll.
11. Finally, ensure to acknowledge the privacy statement and, if required, have the legal guardian sign if the patient is under 18 years of age.
12. Once all sections are completed, remember to save changes, download, print, or share the form as needed.

Start your enrollment in the Coloplast Care Program online today to access valuable resources and support.