Get Amag Assist Reimbursement Program Enrollment Form - Needymeds

Filling out the AMAG Assist Reimbursement Program Enrollment Form online can be a straightforward process if you have clear guidance. This comprehensive guide provides step-by-step instructions to help you complete the form efficiently and accurately.

Follow the steps to successfully complete the enrollment form.

1. Press the ‘Get Form’ button to start the process of obtaining the form. This action will allow you to access the form for online filling.
2. Begin with the provider information section. Fill in the physician's name, specialty, facility name, address, phone number, and the tax ID and NPI if applicable. Ensure all details are accurate for processing.
3. Next, move to the patient information section. Input the patient’s name, date of birth, social security number, and address. Include the contact information for the person completing the form, if different from the patient.
4. In the patient insurance information section, you will need to provide details about the patient’s primary and secondary insurance companies, including policy numbers and phone numbers. Indicate whether the patient is Medicare eligible and provide diagnosis information.
5. Fill out the clinical information. Indicate if the patient is on dialysis or ESA therapy and provide previous iron therapies and any relevant patient diagnosis details.
6. Continue to the product information section by specifying how will be supplied, dosage, and estimated treatment start date. Complete the shipping address fields if they differ from the above.
7. Complete the patient financial information. Provide the annual household income and the total number of people living in the household. Ensure all required fields are filled out, especially those marked with an asterisk.
8. Review all provided information for accuracy. Make any necessary corrections before proceeding.
9. Once the form is complete, save any changes made. You may wish to download and print the form for your records before submission.

Begin the enrollment process now by filling out your form online to take advantage of the AMAG Assist Reimbursement Program.