Get Coaguchek Enrollment Form

Filling out the Coaguchek Enrollment Form online can streamline the enrollment process for patients requiring anticoagulation management. This guide provides clear and supportive instructions to help users effectively complete the form and facilitate their enrollment in Coaguchek Patient Services.

Follow the steps to complete the Coaguchek Enrollment Form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. In the Patient Information section, provide the patient’s first name, middle initial, last name, gender, address, city, state, zip/postal code, primary phone number, secondary phone number (if applicable), date of birth, and email address (if available).
3. Complete the Assignment of Benefits and Release of Information section by reading the statement and signing and dating where indicated.
4. For the Physician Order section, select whether it is a new prescription or a prescription reactivation. Enter the patient’s information, medical diagnosis codes, and contact information for results.
5. Indicate the patient training option, selecting whether the training will be conducted by the clinic/practice, CoaguChek Patient Services, or if the patient has been previously trained.
6. Fill in the physician's authorization section, including the physician's signature, the date of signing, and their printed name.
7. Provide insurance information, including the insurance company name, policy ID number, and customer service phone number.
8. Review all sections to ensure completeness and accuracy before submitting.
9. Mail or fax the completed form to CoaguChek Patient Services using the provided contact information.

Complete your Coaguchek Enrollment Form online today to ensure a smooth enrollment process!