Get Patient Enrollment Form - Hymovis

Completing the Patient Enrollment Form for Hymovis is a crucial step in accessing the necessary support and benefits. This guide will provide you with clear instructions to assist you in filling out the form accurately and efficiently online.

Follow the steps to accurately complete the enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the patient information section, which is required for all requested services. Enter the patient's first name, last name, address, city, phone number, gender, date of birth, and zip code.
3. In the primary insurance section, provide the necessary details including the name of the insurance provider, policy number, subscriber’s name, date of birth, group number, and address. Ensure to attach copies of the patient's insurance cards.
4. If the patient has secondary insurance, complete the secondary insurance section with similar details as the primary insurance, including name, policy number, subscriber’s information, and address.
5. Fill in the therapy and diagnosis information. Specify the injection site (right knee, left knee, or bilateral), product details, and dose. Indicate any allergies the patient may have.
6. Address whether the patient has a failure, contraindication, or intolerance to specified treatment options by checking the appropriate boxes.
7. Indicate if the patient has tried other medications for their condition. If yes, provide details regarding the medication, duration of therapy, and response.
8. Clearly state the primary diagnosis using the provided codes.
9. Complete the prescriber information section including first name, last name, address, phone number, specialty, and other required details.
10. The prescriber must verify the information is complete and accurate. They will need to sign and date the application to confirm authorization.
11. Once all sections are completed, review the form for accuracy, saving changes as necessary. You can then download, print, or securely share the form as required.

Begin filling out the Patient Enrollment Form - Hymovis online today to ensure timely access to your benefits.