Get Enrollment Form For (sipuleucel-t) And Patient ...

This guide provides a comprehensive walkthrough for users on how to accurately fill out the enrollment form for sipuleucel-t and patient assistance online. By following these steps, you can ensure that you complete the form correctly and submit it hassle-free.

Follow the steps to fill out the enrollment form accurately.

1. Press the ‘Get Form’ button to access the enrollment form and open it in your preferred online editor.
2. Begin with the section for prescribing physician information. Provide the physician's name, infusion site name, complete address, city, state, zip code, phone number, fax number, email address, and specialty. Include the physician's DEA number, patient transaction access number, tax ID number, and national provider identifier, as well as the site's information if different.
3. In the patient information and insurance section, fill out the patient's name, date of birth, social security number, email address, and address. Also, provide primary and secondary phone numbers, as well as primary and secondary diagnosis codes.
4. Complete the insurance information for both primary and secondary insurance, if applicable. Include the primary insured's name, employer, phone number, policy number, group number, and health plan's name.
5. You must fill out the patient authorization for use/disclosure of health information section, which requires the patient to sign and date, confirming their consent for the necessary information disclosure to Dendreon Corporation.
6. If interested in patient assistance programs, complete the relevant sections for co-pay assistance, travel assistance, or uninsured patients. Fill in required fields related to annual household adjusted gross income and the number of household members.
7. Obtain both the patient and physician's signature and the respective dates on the certification and acknowledgment sections to finalize the application.
8. After completing the form, review all the information for accuracy and completeness. Save any changes, then download, print, or share the completed form as needed.

Complete your enrollment form online today to ensure a smooth process.