Get Pace Enrollment Form -

Completing the PACE Enrollment Form is an important step to access the necessary support for treatment. This guide provides clear and supportive instructions to help users navigate the online form with confidence.

Follow the steps to successfully complete the PACE Enrollment Form.

1. Press the ‘Get Form’ button to obtain the PACE Enrollment Form and open it in your preferred digital format.
2. Start by entering the physician information. Fill in the physician's full name, practice or facility name, and specialty. Include the medical education number, street address, city, state, zip code, DEA number, phone number, PTAN number, fax number, NPI number, office contact name, license number, tax ID number, and additional phone and fax numbers.
3. Next, input the patient information. Provide the patient’s first and last name, date of birth, street address, gender, city, state, zip code, phone number, and fax number.
4. Complete the treatment information section. Indicate the site of service, prior therapy undergone, and the required diagnosis and service codes. Additionally, provide details about the dose, units, and injection sites.
5. Fill out the primary insurance information. You may attach a copy of the patient’s insurance card instead of manually entering this data. Include the insurance company’s name, contact numbers, subscriber details, and policy information.
6. If applicable, complete the secondary insurance information in a similar manner to the primary insurance section.
7. Proceed to the prescriber attestation. The prescriber must sign and date this section, confirming that therapy is medically necessary and complies with program rules.
8. Fill out the patient consent section, allowing healthcare providers to disclose personal health information. The patient or legal representative should sign and date this authorization.
9. If participating in the Co-Pay Assistance Program, authorize enrollment and provide necessary signatures and dates.
10. Review all filled sections for accuracy. Save your changes, and decide whether to download, print, or share the form as needed.

Take the next step and complete your PACE Enrollment Form online today.