Follow the steps to correctly fill out your patient information form.

1. Press the ‘Get Form’ button to access the OPUS Health Patient Information form and open it for editing.
2. Provide your name in the format of Last, First. Ensure that the name matches your official documents to avoid any discrepancies.
3. Enter your complete address, including street, apartment/suite number (if applicable), city, state, and zip code.
4. Fill in your email address. This will be used only for claim status notifications; it will be kept confidential.
5. Enter your phone number, including area code, ensuring it is correct for potential follow-up regarding your claim.
6. In the insurance information section, indicate whether you have health insurance by checking the appropriate box. If applicable, provide the name of your insurer for prescription benefits.
7. State whether your insurance covered the prescription in full, not at all, or if there was a copay amount. Complete the relevant details based on your situation.
8. Indicate where the prescription was filled, either at a retail pharmacy or via mail order or specialty pharmacy, and be aware that certain claims may require additional documentation.
9. Gather required documents, including the original pharmacy receipt and any necessary Explanation of Benefits (EOB), as per the instructions provided.
10. Review the certification statement and ensure you understand its implications. Sign and date the form where indicated.
11. After completing the form and attaching all necessary documents, submit your claim to the specified OPUS Health address.

Begin completing your OPUS Health Patient Information form online today.