Get Start Form - Information For Healthcare ...

Filling out the Start Form - Information For Healthcare is an essential step in accessing necessary medical treatments. This guide provides clear and supportive instructions to help users successfully complete the form online, ensuring all required information is accurately provided.

Follow the steps to fill out the Start Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the patient information section. Fill in the patient's first name, middle initial, last name, date of birth, gender, and home address including city, state, and ZIP code. If the shipping address is different from the home address, provide that information as well.
3. Complete the contact information for the patient including the telephone number, alternate telephone number, best time to call, preferred language if not English, and email address.
4. If applicable, provide information about the patient representative, including their relationship to the patient and contact telephone number.
5. In the insurance information section, provide details for pharmacy benefits and primary medical insurance. Include copies of insurance cards as required.
6. Move on to the healthcare provider information. Fill in the healthcare provider's first and last name, middle initial, specialty, NPI number, group NPI number if applicable, and state license number.
7. Proceed to the prescription section. Indicate the diagnosis and the medication dosage. Complete necessary fields for the number of vials and refills, along with the route of administration.
8. In the consent and statement of medical necessity section, ensure the healthcare provider's signature and date are included to validate the prescription.
9. Complete the patient authorization section. If the patient is not available, the Support and Access Team will obtain authorization upon receiving the referral.
10. Finally, review all information for accuracy, then save your changes. You can download, print, or share the form as necessary before faxing it to the specified number.

Take the first step toward accessing your treatment by completing the Start Form online today.