Get Patient Enrollment Bformb - Varithena

Filling out the Patient Enrollment Form for Varithena online can be a straightforward process if you follow the proper guidelines. This guide offers clear, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete your Patient Enrollment Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the Patient Information section. Fill in the mandatory fields like the patient’s name, date of birth, address, city, state, zip code, and daytime phone number. Ensure accuracy as this information is vital for identification.
3. Proceed to the Insurance Information section. If you have a copy of the insurance card, it can be uploaded instead of filling out this section. Otherwise, provide the primary and secondary insurance company details, including policy numbers, provider IDs, and contact information.
4. In the Prescriber Information section, enter the treating physician's name, practice address, and contact details. Include their Medicare PTAN and Tax ID, as well as the prescriber’s signature and date, if required.
5. For the Site of Service Information, check if the site is the same as the prescriber. If not, provide the name, address, and other required details for the site where treatment will occur.
6. Fill out the Clinical Information section, specifying the projected treatment date and diagnosis code. Indicate whether the treatment will be completed on the right leg, left leg, or bilaterally.
7. In the Prescription Information section, specify the quantities of Varithena units to dispense and ensure the prescriber's signature is included for validation.
8. Review the Authorization section carefully. The patient or their legal representative must sign, date, and print their name, indicating consent for the exchange of protected health information.
9. Once all sections are completed, review the entire form for accuracy. You may save changes, download, print, or share the completed form as required.

Complete the Patient Enrollment Form online today for an efficient enrollment experience.