Get Benefits Investigation And Patient Assistance Program

Completing the benefits investigation and patient assistance program form is a crucial step in accessing necessary medical support. This guide will provide clear and detailed instructions to assist you in accurately filling out the form online.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Enter the first name, last name, address, city, state, zip code, phone number, gender, and date of birth. Ensure all required fields are completed accurately.
3. Provide primary insurance details, including policy number, subscriber’s name, and attach a copy of the patient's insurance card. Repeat this step for secondary insurance if applicable.
4. In the therapy and diagnosis information section, specify the injection site, quantity, product, and dosage where indicated. Document any relevant allergies and previous treatments the patient has tried.
5. Fill in the prescriber information. Include the prescriber’s first name, last name, contact details, and professional identifiers such as the NPI number and tax ID. Ensure this section is fully completed for shipping purposes.
6. The physician must review and sign the application certifying the information is accurate. Ensure that the patient and prescriber certifications are signed and dated where required.
7. Once all sections are completed, review the entire form for accuracy. Make any necessary corrections before sending.
8. Save any changes made to the form. You can then download, print, or share the completed document as needed to fax to the provided number.

Take action today and complete your benefits investigation and patient assistance program application online.