Get Eligible Patients May Receive Up To 25%, 50%, Or Even

This guide provides clear and detailed instructions on how to fill out the Eligible Patients May Receive Up To 25%, 50%, Or Even enrollment form. Users will find step-by-step directions tailored to support their needs in completing the form online.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to obtain the enrollment form and access it in your chosen format.
2. Fill out the patient information section by providing your last name, first name, date of birth, and gender. Ensure accuracy in these details, as they are critical for your application.
3. Provide your preferred email address for contact, along with the email addresses of your healthcare provider and pharmacy. This information helps ensure efficient communication.
4. List your home phone and mobile phone number to facilitate contact. Then, complete your street address, city, state, and ZIP code.
5. Indicate whether you are undergoing treatment with a fertility specialist. If so, write down the physician’s name. This information is essential for assessing your eligibility.
6. State if you have received products through DesignRx First Steps in the past by selecting 'Yes' or 'No'. This may impact your application process.
7. Specify which medications you have been prescribed by selecting the appropriate options such as , , or .
8. Prepare to submit your income verification form by gathering the required income documents listed in the instructions. Ensure you have the annual adjusted gross income for your entire household.
9. Indicate the number of people living in your household as this information may affect the assistance you receive.
10. Sign and date the form to certify that all provided information is accurate. Make sure to read and understand the terms regarding the authorization to use and disclose health information.
11. Once completed, save changes, download or print the form as needed. You can also share it with the appropriate parties via email or fax.

Complete your enrollment form online today to access potential savings on your fertility medications.