Get Needymeds Sanofi Patient Connection Form

The Needymeds Sanofi Patient Connection Form is designed to help users access necessary medication and financial assistance programs. This guide provides step-by-step instructions on how to complete the form online efficiently and accurately.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Begin by filling in the patient information section. This includes first name, middle initial, last name, address, gender, phone number, city, state, zip code, date of birth, social security number, email address, and primary language. Ensure all details are correct and current.
3. Indicate whether the patient has no insurance and provide the primary insurance details, including policy number, policy holder name, date of birth, and group number. If applicable, also list the secondary insurance information.
4. In the treatment and prescribing information section, specify the medications required (e.g., or ), along with the appropriate ICD-10 codes, dosages, quantities, and refill information as necessary.
5. Complete the prescriber information section, entering the prescriber’s name, license number, NPI number, facility information, and contact details for the prescriber’s office.
6. For the resource connection section, indicate whether the patient wishes to be contacted for additional resources. Select the resource options that may be relevant to the patient.
7. In the patient assistance connection section, provide the total number of people in the household and annual household income. Ensure to understand the privacy implications of the information you’re authorizing for release.
8. Verify that all signatures required for the application are provided, including patient and prescriber signatures, where necessary.
9. Review the application checklist to confirm that all required fields and signatures are completed. This may involve checking HIPAA consent and other specified information.
10. Once the form is completed, save your changes. You may download, print, or share the completed form as needed before submission.

Complete your application online to access essential medication assistance today.