Get Berinert Expert Network (b.e.n. Patient Enrollment Form

The Berinert Expert Network (B.E.N.) Patient Enrollment Form is an essential document for users seeking to enroll in the B.E.N. program. This guide will walk you through each section of the form, ensuring a smooth online completion process to access important support and insurance benefits.

Follow the steps to fill out the B.E.N. form online seamlessly.

1. Click ‘Get Form’ button to access the enrollment form. This will open the form in your preferred editor for completion.
2. Begin filling out the 'Your Information' section with your full name, date of birth, and choose your gender. Additionally, provide your complete address, phone number, and email address.
3. In the 'Insurance Information' section, fill in details about your primary and secondary insurance providers. This includes the insurance company name, phone number, policy number, group number, policy holder’s name, and birth date.
4. Next, complete the 'Physician Information' section. Provide the name of your physician, the name of their facility, and pertinent contact information, including phone and fax numbers.
5. In the 'Support Options' section, indicate your interest in the Berinert Co-Pay BENefit or B.E.N. P.A.L.S. program by selecting or deselecting the checkboxes as per your preference.
6. If applicable, authorize the release of your information to the US Hereditary Angioedema Association (HAEA) by marking the corresponding checkbox.
7. Lastly, sign and date the authorization section at the bottom of the form to confirm that all information is accurate and complete.
8. Once all sections are filled out, you can save your changes, download, or print the completed form. Submit it via fax or mail as directed.

Complete your Berinert enrollment form online now to access vital support and resources.