Get Patient Enrollment Form

Completing the Patient Enrollment Form online is a vital step for individuals seeking treatment with . This guide will provide you with step-by-step instructions to ensure you fill out the form accurately and efficiently.

Follow the steps to complete the Patient Enrollment Form.

1. Click the ‘Get Form’ button to access the Patient Enrollment Form and open it in your preferred editor.
2. Begin filling out the patient information section. Provide the last name, first name, middle initial, date of birth, gender, and phone number. Ensure that the details are accurate and complete.
3. Enter the provider information, including the provider's name, site name, address, city, state, zip code, contact name, telephone number, and specialty. If relevant, attach copies of the demographic sheet and insurance cards.
4. Complete the patient insurance information section by entering details such as the medical and prescription card numbers, member ID, group number, and policy holder name if it differs from the patient.
5. Indicate the patient diagnosis code by selecting the applicable diagnosis, either Irritable Bowel Syndrome with Diarrhea or Hepatic Encephalopathy.
6. Provide treatment information by specifying the dosage and refills required for 550 mg tablets. Ensure all information regarding previous treatments tried and failed is filled correctly, checking all relevant options.
7. The healthcare provider should sign and date the form, certifying that they have the necessary authorization to submit this information. Verify that the provider's identification details, such as NPI number and state license number, are accurate.
8. Before finalizing, review the entire form to ensure accuracy. Save changes, then download, print, or share the completed form as needed. Once ready, fax the document to the provided number.

Complete your Patient Enrollment Form online today for a smooth enrollment process.