Get Enrollment Form

Filling out the Enrollment Form online is a straightforward process that helps streamline patient assistance requests. This guide provides step-by-step instructions to ensure you accurately complete each section of the form.

Follow the steps to successfully complete your Enrollment Form online.

1. Click ‘Get Form’ button to obtain the Enrollment Form and open it in your preferred online editor.
2. In Section 1.1, indicate the support you are requesting by checking all applicable boxes, such as Patient Assistance Program, Benefits Investigation, and others.
3. Proceed to Section 2.1 to enter your personal information. Fill in your first name, middle initial, last name, social security number, gender, date of birth, home phone, cell phone, email, and complete your address details.
4. In Section 2.2, provide your insurance information. Indicate if you are uninsured, then fill out the fields for primary and secondary insurance, including insurance names, policy numbers, and contact details.
5. Section 2.3 requires detailed diagnosis and treatment information. Specify the conditions for each eye, include relevant ICD codes, visual acuity, confirm if treatment has started, and note the anticipated treatment date.
6. Section 3.1 pertains to the prescription for . Document any drug allergies, specify the number of vials needed, and indicate if a specialty pharmacy is required. Also, provide the shipping address if different.
7. Complete Section 4.1 by entering the prescribing physician's information including their practice name, contact details, specialty, state license number, DEA number, and tax ID.
8. In Section 4.2, input the primary office contact information for efficient communications.
9. Section 4.3 requires the physician's certification. The physician must sign and date the section to confirm the accuracy of the information provided.
10. Fill out Section 5.1 to authorize the disclosure and use of health information as necessary. Sign and date to confirm understanding.
11. In Section 5.2, provide your total household income information, and in Section 5.3, certify the accuracy of the application by signing and dating.
12. Finally, ensure all sections are completed accurately. Save changes, download, print, or share the form as needed before submission.

Complete your Enrollment Form online today to streamline your assistance request.