Get Patient Enrollment Form - Iluvien

Filling out the PATIENT ENROLLMENT FORM - Iluvien is a vital step in accessing treatment and support services. This guide will provide you with a clear and structured approach to completing the form online, ensuring that you provide all necessary information accurately.

Follow the steps to complete your enrollment efficiently.

1. Press the ‘Get Form’ button to access the PATIENT ENROLLMENT FORM, then open it in your preferred online editor.
2. In the 'Patient Information' section, enter the patient's first name, middle initial (if applicable), and last name. It is essential to fill in these details or attach the EMR Face/Demographic Sheet.
3. Provide the patient's date of birth, gender, patient EMR number, social security number, and primary language. Make sure to validate the accuracy of this information.
4. Enter the primary phone number and address details, including the city, state, and ZIP code. This information is crucial for contact purposes.
5. Navigate to the 'Prescriber & Office Information' section and fill in the prescribing physician's first and last name, along with the necessary details regarding the place of service.
6. Attach copies of the patient’s insurance card(s) as required. Indicate whether these attachments are included with this enrollment.
7. Complete the 'Treatment Information and Patient History' section by entering the date of primary diagnosis, anticipated date of treatment, and prior corticosteroid treatment details.
8. In the 'Patient Authorization' section, read through the details carefully, and ensure that the patient or legally authorized person signs and dates the authorization to proceed.
9. Once all information is inputted and reviewed, save your changes. You can print, download, or share the completed form as needed.

Complete the enrollment online today to access the necessary support and treatment.