Get Now You Can Provide The Benefits Of Omidriawithout

Filling out the Now You Can Provide The Benefits Of OMIDRIAwithout form is a straightforward process designed to help patients receive the benefits of OMIDRIA. Follow this guide for a clear step-by-step approach to ensure all information is accurately provided.

Follow the steps to complete the patient enrollment form effectively.

1. Press the 'Get Form' button to access the patient enrollment form and open it in the editor of your choice.
2. Carefully fill out all relevant fields on the Patient Enrollment Form, located on the reverse side of the document. Ensure you provide complete and accurate information regarding the patient.
3. Have the surgeon sign the Physician Certification section on the reverse side of the form, confirming that the information is truthful and authorized.
4. Once the form is fully completed and signed, fax the document to 1-855-664-3741 to submit it for processing.
5. Following submission, you will receive a notification regarding the benefit verification status for OMIDRIA based on the patient's insurance.
6. If applicable, discuss potential enrollment in the 'Equal Access' Patient Assistance Program or the 'We Pay the Difference' Commercial Reimbursement Program for your patient.
7. To complete the process, remember to keep a copy of the form for your records. You may also download, print, or share the completed form as needed.

Start filling out the form now to ensure timely benefits for your patients.