Get On Track Enrollment Form

This guide provides step-by-step instructions for completing the On TRACK Enrollment Form online. Designed for ease of use, it aims to support all users in properly filling out the necessary information required for enrollment.

Follow the steps to complete the enrollment form online seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online document editor.
2. Begin by entering the patient information in the designated fields. Provide the full name, gender, date of birth, address, city, state, primary phone number, alternate phone number, and zip code.
3. Next, proceed to the patient medical information section. Indicate the primary diagnosis using the ICD-10 codes provided, and specify any secondary diagnoses if applicable.
4. In the physician information section, fill in the prescriber’s name, practice name, phone number, fax number, email address, office contact name, and the primary and secondary addresses along with relevant zip codes.
5. Input the necessary prescription drug information. Specify if the patient is currently on therapy, how the medication should be delivered, and provide details regarding the treatment setting.
6. Complete the prescriber consent section by entering the prescriber’s name, signing where indicated, and providing the date.
7. Once all fields are filled out, review the form for accuracy and completeness. Ensure all required fields are completed before proceeding.
8. Finally, save the changes, and choose to download, print, or share the completed form as needed.

Complete your forms online to streamline the enrollment process and ensure timely submission.