Get Sandoz One Source Enrollment Form - Needy Meds - Needymeds

Completing the Sandoz One Source Enrollment Form online is essential for accessing necessary treatment and support. This guide will walk you through each section of the form, ensuring that you understand the requirements and can submit your information accurately.

Follow the steps to complete your enrollment form.

1. Press the ‘Get Form’ button to obtain the Sandoz One Source Enrollment Form and open it in your preferred editor for online completion.
2. Begin with Section 1, which requires patient information. Fill in the patient's first name, middle initial (if applicable), last name, address, date of birth, social security number, and contact information. It's important to ensure all details are accurate.
3. In Section 2, include both the primary and secondary insurance information for the patient. You may also attach a copy of the patient's insurance cards for convenience. If the patient does not have insurance, check the 'No Insurance' box.
4. Proceed to Section 3, where you will enter the drug name, treatment details, and prescribing information. Ensure that any necessary prescriptions are attached if applicable.
5. Complete Section 4 with the prescriber's information, including their name, type, NPI number, and contact details.
6. In Section 5, have the patient provide their authorization and signature. This step is crucial for allowing the necessary information to be shared with Sandoz.
7. Next, in Section 6, the prescriber must sign their authorization confirming the treatment is medically necessary.
8. If enrolling in the Commercial Co-Pay Program, ensure Section 7 is signed by the patient. If applying for the Patient Assistance Program (PAP), skip this section.
9. Lastly, if applicable, complete Section 8 with patient consent for the PAP. Include financial information and the total number of people in the household, with relevant income documentation as needed.
10. Review all completed sections for accuracy, then save any changes. You may choose to download, print, or share the form as required.

Complete your Sandoz One Source Enrollment Form online today to ensure timely processing of your request.