Get Enrollment Form

Completing the enrollment form online is a straightforward process designed to help facilitate your treatment with . This guide will walk you through each section, ensuring you have all necessary information on hand for a seamless submission.

Follow the steps to complete the enrollment form accurately.

1. Click ‘Get Form’ button to access the enrollment form and fully open it for editing.
2. Fill in the patient information section, including the patient name, street address, city, state, zip code, preferred phone number, email address, date of birth, and social security number. Ensure all required fields are completed accurately.
3. In the treatment history section, specify the LDL-C on treatment, the date, and any details regarding the current or previous medications used, including dosages. Indicate if maximum tolerated doses have been achieved and any failures or contraindications to previous therapies.
4. Provide family history of atherosclerotic cardiovascular disease and list any allergies that may impact treatment.
5. Next, include the pharmacy insurance information. Attach a copy of the insurance card(s) and complete the pharmacy insurance ID and telephone number fields.
6. If the pharmacy insurance information is not available, complete the primary or secondary medical insurance information section, also attaching the insurance card(s) and ensuring required fields are filled out.
7. In the medical information section, provide at least one primary and one secondary ICD-10-CM code as required.
8. Complete the prescription information section, indicating the product name, dosage, days’ supply, and refill information.
9. Fill out the prescriber information, including contact details, prescriber name, specialty, and NPI number. Ensure the signature section is completed by the prescriber with the necessary dates.
10. Before finalizing, review all information for accuracy. Once complete, save your changes, and you can choose to download, print, or share the form as needed.

Begin completing your enrollment form online today to ensure timely access to your treatment.