Get First Steps Enrollment Form - Mandells Pharmacy

Filling out the FIRST STEPS ENROLLMENT FORM for Mandells Pharmacy is an essential step for individuals seeking assistance with their fertility treatments. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete your enrollment form.

1. Press the ‘Get Form’ button to access the FIRST STEPS ENROLLMENT FORM and open it in your preferred editor.
2. Begin by entering your patient information. Fill in the sections for last name, first name, date of birth, gender, home phone, email address, mobile phone, and your preferred method of contact. Ensure that all information is accurate and up-to-date.
3. In the treatment section, indicate whether you are currently undergoing treatment with a fertility specialist by selecting 'yes' or 'no.' If 'yes,' provide the physician's name.
4. Next, mention if you have ever received products through DesignRx First Steps before. If applicable, check the items you have been prescribed from the list provided.
5. You will need to submit documentation for income verification. Choose the appropriate income document from the list provided, such as a 1040 Form or W2, to validate your annual adjusted gross income.
6. Indicate the number of people living in your household. This information may be used for your application process.
7. Sign and date the form in the designated sections to certify that you have completed all sections accurately and agree to the terms stated in the enrollment form.
8. Lastly, ensure that all information is correct and complete. You can then save changes, download, print, or share the completed form as required.

Start filling out your FIRST STEPS ENROLLMENT FORM online today to take the first step towards your fertility treatment.