Get Go Program

The Go Program facilitates access to ® for patients and health care providers. This guide provides a comprehensive overview of how to fill out the associated Service Request Form accurately and efficiently online.

Follow the steps to complete the Go Program Service Request Form.

1. Press the ‘Get Form’ button to retrieve the Service Request Form, which will open in the designated editor for your convenience.
2. Ensure that your patient has read the Patient Authorization and Marketing Consent Information, then ask them to complete Section 1 of the Service Request Form. This section requires their personal details and consent.
3. As a health care provider, fill out Section 2 on the form with your information and sign where indicated. This signature is crucial for your patient to proceed with the treatment.
4. Continue completing any remaining fields on the Service Request Form, which may require consultation of the patient's insurance details. If applicable, make photocopies of the patient’s insurance and pharmacy benefit cards.
5. Once all sections of the form are complete, hand your patient the relevant instructions and consent information documents. Then, fax the completed Service Request Form along with the insurance card copies to the specified fax number.
6. After submission, expect further communication from the patient’s Navigator regarding benefit verification and scheduling of necessary appointments.

Take the step now to complete your Go Program documentation online.