Get Patient Enrollment And Consent Form Enroll ... - Accredo - Needymeds

Filling out the patient enrollment and consent form is a crucial step for individuals seeking treatment through the program. This guide will provide clear and supportive instructions to ensure you navigate the online form effectively.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the form. Once obtained, open it in your preferred editor for completion.
2. Begin with the 'Patient Information' section. Fill in required fields marked with an asterisk, including the first name, last name, and birthdate. Ensure the contact details are accurate for effective communication.
3. In the 'Female Patient Agreement' section, if applicable, review the information carefully and provide the necessary acknowledgment by signing and dating as required.
4. Proceed to the 'Prescriber Information' section. Complete all mandatory fields to ensure effective processing of the prescription.
5. Enter prescription details in the 'Prescription' section. Specify the initial dose, quantity, and refills required while indicating special instructions if necessary.
6. In the 'Prescriber Authorization' section, indicate the reproductive status of female patients and ensure the required certification is completed and signed.
7. Complete the 'Statement of Medical Necessity' section by providing the diagnosis and ICD-10 code as specified in the form.
8. Fill in the 'Written Permission to Share Information' section, acknowledging data sharing policies. Sign and date where requested.
9. Once all sections are completed, review the form for accuracy. Save your changes, download a copy for your records, and follow the submission instructions to submit it online or via fax.

Complete your documents online to ensure timely processing and support for your treatment needs.