Get Free Trial Plus Enrollment Form - M Eloctatepro.com

This comprehensive guide provides clear instructions on how to successfully complete the Free Trial Plus Enrollment Form for ELOCTATE. By following the steps outlined below, users can ensure their forms are filled out correctly for a smooth enrollment process.

Follow the steps to fill out the Free Trial Plus Enrollment Form.

1. Press the ‘Get Form’ button to access the Free Trial Plus Enrollment Form and open it in the designated editor.
2. Read through the HIPAA Authorization to Share Health Information, Patient Services Authorization, and optional Opt-In to Receive Marketing Communications located on page 2. This ensures you understand the information required in sections A, B, and C.
3. On page 3, sign in the yellow highlighted areas found in sections A and B either through eSignature or by printing and signing manually.
4. If you wish to opt-in, fill out section C; otherwise, proceed to complete sections D and E with your personal information.
5. Review and ensure all information is accurate, including any attachments of the front and back of your insurance card.
6. If ELOCTATE seems suitable for your needs, instruct your healthcare provider to fill out sections F and G (including their signature in section H) and fax the entire completed form to 1-855-398-7634.
7. After submitting the form, you and your healthcare provider will receive a call from a MyELOCTATE Coordinator to confirm your health insurance coverage and discuss delivery options.
8. Ensure to save any changes made to the form, and consider downloading, printing, or sharing it as needed for your records.

Complete your enrollment form online now to begin your free trial of ELOCTATE.