Get Together With Tesaro Program Enrollment Application - Needymeds

This guide provides a step-by-step approach to completing the TOGETHER With TESARO Program Enrollment Application available online. Whether you are helping a patient enroll or filling out the form for yourself, this guide will ensure you navigate the application process smoothly.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to obtain the form and open it in the designated online editor.
2. Begin by filling out the patient information section, including the patient’s name, sex, date of birth, and contact details such as home phone, cell phone, and email.
3. Indicate the services requested for the patient by checking all relevant boxes, including options for insurance investigation, co-pay assistance, referrals, and first dose access.
4. Provide prescription information by checking the relevant box for VARUBI and specifying the quantity desired and the preferred dispensing location.
5. Complete the prescriber information section by filling in the prescriber’s name, NPI number, DEA number, PTAN, and tax ID, as well as the site or facility name and contact information.
6. In the clinical information section, indicate the patient’s diagnosis, ICD code, and target start date, while also listing any drug allergies.
7. Fill out the insurance information, ensuring to check if the patient has insurance, and include relevant details such as policy IDs and relationships to the policyholder.
8. Indicate the preferred shipping location for the medication by selecting either the prescriber’s office or another address.
9. Review Section 8, where the prescriber must sign and provide consent regarding the use of patient information for the program.
10. Once all sections are completed, save your changes. You can download, print, or share the filled-out form as needed.

Complete your application online today to access the TOGETHER With TESARO program.