Get Flexible Initiation Of Treatment Fit Program For Ruxolitinib Sign Your Patients Up For Fit

This guide provides clear and comprehensive instructions on how to fill out the Flexible Initiation Of Treatment (FIT) Program for ® (ruxolitinib) online. By following these steps, you can ensure a smooth application process for your patients.

Follow the steps to complete the FIT Program enrollment form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In the first section, enter the physician or licensed prescriber name, state license, NPI, site facility name, street address, city, state, office contact, phone number, and fax number.
3. For provider information, confirm if the patient will use for treating intermediate or high-risk myelofibrosis by selecting 'Yes' or 'No'. Additionally, provide the patient's current platelet and hemoglobin levels if available.
4. In the patient information section, enter the patient's name, shipping address, city, alternate contact name and relationship, phone number, and date of birth.
5. Indicate whether you request insurance verification by checking the appropriate box. This step allows IncyteCARES to verify insurance details for the patient.
6. Fill out the previous or current myelofibrosis therapies section, indicating 'Yes' or 'No' as to whether the patient has previously received any MF therapies.
7. In the prescription section, enter the patient's name, date, product name (), dosage (only 5-mg tablets available), directions, and confirm the quantity (no refills allowed). Select where to ship the prescription (either to the patient's home or the doctor's office).
8. Complete the physician or licensed prescriber signature section and date it to authorize the request.
9. In the patient authorization section, ensure that the patient or their representative signs and dates the authorization, allowing the disclosure of personal health information necessary for the FIT Program.
10. After filling out all sections accurately, review the information for completeness. You can save changes, download, print, or share the completed form as required.

Begin the process today by completing the FIT enrollment form online.