Get 3 Copay Assistance Program Only Enrollment How To Enroll The Entyvio Connect Copay Assistance

This guide provides step-by-step instructions on how to fill out the 3 Copay Assistance Program Only Enrollment form for Entyvio Connect. By following these instructions, users can ensure a smooth enrollment process and access financial assistance with out-of-pocket costs.

Follow the steps to complete your enrollment form accurately.

1. Click ‘Get Form’ button to access the enrollment form. This will allow you to open the form in your preferred document editor.
2. Begin by filling out the patient information section. Include the patient's full name, mailing address, home and cell/work phone numbers, email, state, city, zip code, and date of birth. Ensure that you indicate the patient's gender as either male or female.
3. Respond to the questions regarding leaving a message for the patient, confirming commercial insurance coverage, and certifying enrollment in any federal or state healthcare programs. Answer each 'Yes' or 'No' question as applicable.
4. Complete the authorization section where the patient agrees to the disclosure of their personal health information. The patient must sign and date this section, along with printing their name.
5. Next, fill out the physician information section. Include the physician's name, site name, address, phone number, fax number, office contact name, and NPI number.
6. The physician must provide a diagnosis code and attest that Entyvio is clinically appropriate for the patient. The physician should sign and date this section.
7. Review the completed form to ensure all required fields are filled out correctly, and that both the patient and physician have signed where necessary.
8. Fax the signed form to 1-877-488-6814 and confirm that all attestation questions have been answered.
9. For assistance or questions, contact Entyvio Connect at 1-855-ENTYVIO during their business hours, Monday to Friday from 8 AM to 8 PM EST.

Encourage others to complete their enrollment forms online by following these detailed instructions.