Get Enrollment Form

This guide provides step-by-step instructions to help users fill out the Enrollment Form online efficiently. By following these steps, users can ensure that all required information is submitted accurately to facilitate the enrollment process.

Follow the steps to successfully complete the Enrollment Form online.

1. Click the ‘Get Form’ button to obtain the Enrollment Form and open it in your online editor.
2. Begin by filling out the Patient Information section. Enter the patient's full name, including the first, middle initial, and last name, along with their date of birth in the specified format (MM/DD/YYYY). Ensure that the address fields are complete, including street, city, state, and zip code.
3. Complete the Prescriber Information section next. This will include the prescriber's full name, specialty, office contact details, and the best contact number. Indicate the preferred number to call whether it's cell, home, or work, and specify the best time to contact.
4. In the Insurance Information section, provide all required details including insurance provider identifiers such as Medicaid/Medicare provider numbers, primary insurance information, and policy numbers. Make sure to include the cardholder's information and relationships where applicable.
5. Detail any Prior Medications taken by the patient. List the medications indicated, ticking those that apply to the patient’s treatment history.
6. Move to Clinical Information: specify the primary and secondary diagnosis codes for the patient’s condition and include any relevant details such as the date of diagnosis and patient weight.
7. In the Patient Authorization section, ensure the patient or their legally authorized representative provides their signature and the date. This confirms their understanding and agreement to share their information as needed.
8. For the Extended Services Enrollment section, review the services offered. The patient should indicate their preferences by signing and dating the relevant boxes.
9. Finally, in the Shipping Information section, complete the necessary details about where the medication should be shipped, be it the provider office or the patient’s home.
10. After thoroughly reviewing all the filled information for accuracy, users can save changes, download a copy for personal records, print the completed Enrollment Form, or share it as required.

Complete your Enrollment Form online today to ensure prompt processing of your application.