Get Jumpstart Authorization Form For ...

This guide provides a step-by-step approach to accurately filling out the JUMPSTART AUTHORIZATION FORM FOR ®, ensuring you complete each section thoroughly and correctly. Whether you are a user with prior experience or new to the process, this guide aims to support your submission online.

Follow the steps to complete your authorization form effectively

1. Click ‘Get Form’ button to access the authorizations form and open it in the editor.
2. Complete the prescribing physician information section. Enter the physician's name, state license number, facility or hospital name, PTAN, tax ID number, and contact details, including phone and fax numbers.
3. Fill out the prescribing information for the patient. Indicate the patient's diagnosis using the ICD-9 code and description. Specify whether the therapy is being administered in a physician's office or another location, and confirm if the doctor is contracted with the patient’s insurance.
4. Provide patient information, including their name, address, date of birth, social security number (SSN), and phone number. Specify if the patient is a U.S. resident.
5. In the insurance information section, answer if the patient has health insurance coverage. If yes, fill in details about commercial or Medicare options available, and provide copies of all insurance cards.
6. Complete the physician signature section, affirming the medical necessity of the drug and the accuracy of the information provided. Include the physician's signature and the date.
7. If requesting free product assistance through the Patient Assistance Program, fill out the related patient and shipping information. Provide total household income and proof of income as required.
8. Review the completed form for accuracy and ensure all sections are filled out as required.
9. Upon completion, save changes, download, print, or share the form as necessary. Return the completed form by fax to the specified number.

Complete your JUMPSTART AUTHORIZATION FORM FOR ® online today to facilitate timely processing.