Get Central Form

Filling out the Central Form online is an essential step for enrolling in the Central Patient Support Program. This guide will provide you with clear instructions and helpful information to ensure your form is completed accurately and efficiently.

Follow the steps to complete the Central Form online.

1. Press the ‘Get Form’ button to access the Central Form. This will allow you to download or view the document in an editable format.
2. Begin by entering the patient's information in the first section titled 'Patient and Insurance Information.' Provide the patient's first name, last name, date of birth, and sex by selecting the appropriate option.
3. Fill in the primary insurance details including the insurance provider's name, phone number, policyholder’s name, and their relationship to the patient. Additionally, enter the policy number, group number, and complete the address fields.
4. Provide prescription insurance information by including the name of the provider, contact number, and relevant numbers such as BIN and PCN. Indicate if the patient allows messages to be left and if the caregiver can be communicated with.
5. For the prescriber information section, enter the prescriber's first and last name, contact details, and address. Ensure you fill in the specialty, office contact name, and include the NPI and Tax ID numbers.
6. Review the Patient Authorization located on page 2 carefully. If you agree to the terms, sign and date the document in the designated area.
7. Finalize your form by saving any changes you've made. Depending on your needs, you can either download, print, or share the completed form.

Take the next step towards enrollment by completing the Central Form online today.