Get Patient Claim Form - Access 360

Filling out the Patient Claim Form - Access 360 is an important step for patients seeking coverage for their out-of-pocket costs related to ®. This guide will provide you with clear instructions for each section of the form, ensuring a smooth submission process.

Follow the steps to complete the form accurately

1. Press the ‘Get Form’ button to access the Patient Claim Form - Access 360 and open it in your preferred document editor.
2. In the 'Administering Physician' section, enter the physician's last name, first name, middle initial, practice name, National Provider Identifier (NPI), phone number, street address, state, and ZIP code. Ensure all fields are filled correctly.
3. In the 'Patient Information' section, provide the patient's last name, first name, and ZIP code. Select whether the patient is a cash patient, under a commercial plan, or under a government plan. Also, fill out the date of birth and insurance details, including primary insurance payer name, group ID, and subscriber ID.
4. Move to the 'Claim Information' section. Here, enter the Visa group number, Visa card ID (11 digits), date of service, and the patient out-of-pocket amount. This information is essential to process the claim.
5. Before submitting, ensure that both the administering physician and the patient are enrolled in the Patient Savings Program. Download the necessary enrollment forms if required.

Complete your Patient Claim Form - Access 360 online today to ensure you receive the benefits you deserve.