Follow the steps to fill out the ZytigaOne form correctly.

1. Click the ‘Get Form’ button to obtain the ZytigaOne form and open it in your editor.
2. Enter the patient information in Section 1. Provide the patient's name (first, middle initial, last), date of birth (MM/DD/YYYY), address, email, and preferred language (English or Spanish). Include the best contact numbers and time to reach the patient.
3. In Section 2, fill out the insurance information. Include primary and secondary insurance details, including the cardholder's name, policy number, group number, and insurance company phone number. Ensure to attach a copy of the insurance card if required.
4. Complete Section 6 with clinical information. Enter the appropriate diagnosis code, ensuring it corresponds to the patient's condition.
5. In Section 7, provide prescription information. If a benefits investigation is requested, complete this section with the prescribed medication, dosage, quantity, and directions for use.
6. Fill out Section 3 with the prescriber’s information. Include their name, address, specialty, office contact details, and any necessary licenses or identifiers.
7. Complete the Patient Authorization section. Ensure the patient reads the authorization statement, then have them sign and date the form. If the patient is unable to sign, a legally authorized representative may do so.
8. Select a preferred specialty pharmacy from Section 8. Check the box corresponding to the chosen pharmacy to expedite the prescription process.
9. Once all sections are complete, review the form for accuracy. Save changes if needed, then print, download, or prepare to fax the completed form to ZytigaOne at the provided number.

Get started now by filling out the ZytigaOne form online to access the support you need.