Get Enrollment Form - Curascript

Filling out the Enrollment Form for CuraScript online is a straightforward process that ensures your prescription and necessary information are documented correctly. This guide will walk you through each section of the form, providing clear instructions to help you complete it accurately.

Follow the steps to successfully complete your Enrollment Form - CuraScript.

1. Click the ‘Get Form’ button to obtain the Enrollment Form and open it for editing.
2. Begin by filling out the Patient Information section. Enter the patient's name, phone numbers, address, and date of birth in the specified fields.
3. Next, locate the Statement of Medical Necessity section. Indicate any known allergies or health conditions. Fill in the expected start date and the patient's weight. Include the primary diagnosis and ICD9 code, along with details about any previous usage of this medication.
4. In the Drug Delivery Information section, choose the appropriate delivery method: in-office, home delivery for self-administration, or home health administration. Specify if prior authorization is required and mention any necessary documentation.
5. Complete the Insurance Information section. You may either fill in the details or fax a copy of the patient’s insurance card. Ensure that all relevant insurance policy numbers and group information are included.
6. Provide Doctor/Prescriber Information. Fill out the prescriber’s name, address, phone number, NPI number, and DEA number if applicable.
7. Complete the Rx section at the bottom of the form. Enter the date, drug name, form, strength, directions for use, quantity, refills, and provide the necessary signatures from the prescriber.
8. Once all sections are filled out accurately, review the entire form for completeness. Users can save changes, download, print, or share the form as necessary.

Get started with completing your Enrollment Form online today!