Get Sativex Patient Assistance Program - Ccic

Filling out the SATIVEX Patient Assistance Program Enrollment Form online can be straightforward with the right guidance. This program aims to support eligible patients in accessing SATIVEX for managing their medical conditions while exploring private reimbursement options.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to open the SATIVEX Patient Assistance Program Enrollment Form for online completion.
2. Begin by filling in the patient information section. Provide the patient's full name and telephone number. Ensure accuracy to facilitate communication with Pharmex Direct and Equitus Consulting.
3. In the section where the patient must agree to participate, ensure the patient understands the program’s details, including the coverage of medication costs and fees.
4. The patient must sign and date the form, confirming their consent and understanding of the program.
5. The physician should fill in their information, including name, address, telephone number, fax number, and email address.
6. Complete the prescription information section by indicating the number of vials prescribed. Options will include 1 to 4 vials.
7. Any additional instructions from the physician should be included in the space provided.
8. The physician needs to sign and date the prescription portion of the form to validate it.
9. Once all sections are completed, ensure the completed form is saved. If necessary, download and print a copy for records before submission.
10. Finally, fax the completed form to Pharmex Direct at 1-800-263-8746 to initiate the process.

Get started today by completing the SATIVEX Patient Assistance Program Enrollment Form online.