Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
2. Begin by entering patient information in the designated sections. Carefully fill out fields such as first name, last name, birth date, and contact information. Ensure accuracy to prevent any issues in processing.
3. Indicate the gender of the patient by selecting the appropriate option, either Male or Female.
4. Specify the primary language and contact details, including email address and phone numbers. Also, provide the best time for a representative to call for follow-ups.
5. Input the emergency contact information. This should include the relationship to the patient and the contact number.
6. In the Actelion Pathways Services Authorization section, read the permissions regarding the sharing of personal and health information. If you agree, provide the required signature and date.
7. If applicable, complete the Female Patient Agreement by checking the appropriate boxes regarding reproductive potential and understanding the associated risks with . Sign and date this section as well.
8. Proceed to the Diagnosis, Prescription, and Shipping Information. Select the diagnosis related to Treatment and fill out additional prescribing details, including the quantity and shipping address.
9. Prescriber information must also be completed. The prescriber must check the correct female patient category and sign the form, indicating their agreement with the prescriber requirements.
10. Once all sections are completed, review the form for accuracy. Save your changes. You can then download, print, or share the form as needed. Finally, fax the completed form along with copies of the insurance cards to the specified number.

Complete your Patient Enrollment and Consent Form - Risk online today for timely access to therapies.