Get Patient Authorization Form - Cabometyx

Completing the Patient Authorization Form - CABOMETYX online is a straightforward process designed to facilitate your participation in the EASE program. This guide will help you navigate each section of the form with clarity and support.

Follow the steps to fill out the Patient Authorization Form - CABOMETYX online.

1. Press the ‘Get Form’ button to access the Patient Authorization Form - CABOMETYX and open it in your online editor.
2. Review the entire form to ensure you understand its purpose and the information required.
3. Fill out the patient name section with your last and first name.
4. Provide your date of birth in the appropriate field.
5. Enter the name of your physician in the designated section.
6. In the Patient Authorization to Use/Disclose Health Information section, read through the authorization carefully. You will need to agree and authorize Exelixis and its representatives to use your personal health information.
7. Initial where required to consent to the sharing of your personal health information, and understand what it entails. This includes consent for financial support services and other services.
8. Sign your name as the patient or representative in the appropriate field. Ensure you date the signature.
9. For the EASE Co-Pay Assistance Program section, provide consent for EASE to enroll you in the program and acknowledge your eligibility regarding federal or state programs.
10. Complete the EASE Patient Assistance Program section by providing your Social Security Number and checking the applicable boxes related to your insurance coverage.
11. Lastly, ensure you add your signature and date in the relevant fields. Review all provided information for accuracy.
12. After completing the form, you can save your changes, download, print, or share the form as needed.

Start filling out your Patient Authorization Form - CABOMETYX online today to ensure your access to essential support services.