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This guide provides a step-by-step process for filling out the enrollment form required for accessing customer service. By following these instructions, users can ensure that their form is completed accurately and efficiently.

Follow the steps to fill out the enrollment form effectively.

1. Click ‘Get Form’ button to obtain the enrollment form and open it in your preferred document editor.
2. Begin by filling in the prescriber information fields, including the *Prescriber Name*, *NPI #*, and *Tax ID #*. These fields are critical as they identify the medical professional responsible for the prescription.
3. Provide the patient's insurance information in the relevant sections. Include details like *Policyholder Name*, *Member ID #*, and *Group ID #*. If applicable, fax the demographic sheet or patient pharmacy card alongside the enrollment form.
4. Complete the patient information section. Key fields include *Patient Name*, *Date of Birth*, and *Home Phone #*. It’s important to ensure accuracy, as this information is crucial for processing the enrollment.
5. In the *Patient Diagnosis* section, enter the *Diagnosis Code* and any known allergies by checking if there is a ‘No known drug allergies’ (NKDA) option.
6. Next, fill in details about the prescription information. Indicate the *Drug* name and dosage required, specifying the preferred quantity (30, 60, or 90 day supply).
7. In the *Provider Attestation* section, ensure to sign and date the form to confirm the information provided is accurate. This step is mandatory for processing the form.
8. Once all sections are completed, review your entries for accuracy. You can then save your changes, download the form, print it or share it as needed.

Take action now and complete your enrollment form online to access customer service support.