Follow the steps to complete the enrollment form effectively.

1. Press the ‘Get Form’ button to obtain the enrollment form and open it in your preferred digital editor.
2. Begin filling out the patient information section. Ensure you include the patient’s name, insurance ID number, parent or guardian name, home phone number, address, alternate phone number, city, state, ZIP code, date of birth in mm/dd/yyyy format, and their sex.
3. In the medical information section, attach relevant medical records that support the patient's diagnosis. Provide all required ICD codes and corresponding diagnoses.
4. Indicate whether this is the first administration of for the requested knee(s) or TMJ site by answering the yes/no questions. Specify the injection site if applicable.
5. Complete the prescription information section by selecting the medication type, dosage strength, directions for use, injection site, quantity needed, and refill options. Ensure correct and clear input for each field.
6. Fill in the prescriber information accurately, including the prescriber’s name, DEA number, address, phone number, suite number, fax number, city, state, ZIP code, contact person, and the prescriber’s signature on the form.
7. Lastly, complete the insurance information section fully. Fill out details for both primary and secondary insurers, including their names, ID numbers, subscriber names, and contact numbers. Attach a copy of the patient’s insurance card, both front and back.
8. Once all sections are thoroughly completed, review the form for any missing information. After confirmation, save changes, and you may either download, print, or share the form as necessary.

Start filling out the enrollment form online today to ensure timely prescription approval.