Get Proceed Patient Assistance Program - Viekira Pak

The ProCeed Patient Assistance Program - VIEKIRA PAK provides a streamlined approach to access treatment for hepatitis C for eligible patients. This guide offers clear, step-by-step instructions to assist users in accurately completing the online form, ensuring a seamless application process.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. In the 'Requested Services' section, select all applicable boxes for the services you are requesting, such as Prescription/Benefit Verification or Patient Assistance Program (PAP) Review.
3. Fill out the 'Patient Information' section with the patient's name, date of birth, gender, contact information, and insurance details. Ensure to include the last four digits of the social security number.
4. Complete the 'Prescriber Information' section, providing details about the prescribing physician, including their name, contact information, and specialty.
5. In the 'Diagnosis and Clinical Information' section, indicate the HCV genotype, treatment history, and provide details about insurance coverage.
6. Proceed to the 'Prescription Information' section where you will check the appropriate box for medication, specify dosage, and list directions, quantity, and refills.
7. Sign and date the form to certify that the information is accurate. Remember, stamps are not allowed for signatures.
8. Review all sections for completeness and accuracy. Once confirmed, save your changes, then download, print, or share the form as needed.

Complete your ProCeed Patient Assistance Program application online today to ensure timely access to your treatment.