Get Quickstart Program Request Form - Pertzye - Needymeds

This guide provides clear instructions for filling out the QuickStart Program Request Form for Pertzye through Needymeds online. Follow these comprehensive steps to ensure all necessary information is accurately submitted.

Follow the steps to complete the QuickStart Program Request Form effectively.

1. Click ‘Get Form’ button to obtain the QuickStart Program Request Form and open it in your preferred editor. This allows you to review and complete the form.
2. In the patient information section, fill in your full name, including first name, middle initial, and last name. Select your sex and provide your weight and height.
3. Input your date of birth in the designated format, and provide your email address. Fill in your home address with city, state, and zip code. If the shipping address is different, complete that section as well.
4. Enter your home phone number and cell number. Understand and check the box acknowledging that your pharmacy may receive remuneration for disclosing your personal health information. Sign and date the form in the space provided.
5. Complete the physician information section by entering the physician's name, contact name, and the practice name or institution. Provide the full address, telephone number, and fax number.
6. In the prescription and statement of medical necessity section, indicate the prescription (Pertzye) by checking the appropriate box for the desired dosage. Specify the dosage and how many caps per day, per meal, and per snack.
7. The prescriber needs to sign and date the form to confirm medical necessity and authorization to release patient information for coverage purposes.
8. After filling out the form, save any changes you made. You can download, print, or share the completed form as needed.

Complete your QuickStart Program Request Form online today to ensure timely processing of your Pertzye prescription.