Get Print And Fax Completed Enrollment Form Free Trial Plus ... - Rxassist

This guide provides a clear and comprehensive walkthrough for completing the Print And Fax Completed Enrollment Form for the Free Trial Plus program. By following these instructions, individuals can smoothly fill out the required fields and submit the form efficiently.

Follow the steps to complete the enrollment form successfully.

1. Click ‘Get Form’ button to obtain the form and access it in the designated editor.
2. Carefully read the HIPAA Authorization to Share Health Information, Patient Services Authorization, and the optional Opt-In to Receive Marketing Communications on page 2. This information is essential for understanding how your health information may be shared.
3. In sections A and B, sign in the yellow highlighted areas. You may use eSignature or print the form and sign it manually.
4. If you choose to opt-in for marketing communications, fill out section C. Otherwise, you may leave this section blank.
5. Complete sections D and E by providing your personal and insurance information. Ensure that all fields are filled accurately to avoid delays.
6. If required, have your healthcare provider complete sections F and G. They will also need to sign in section H.
7. Fax the completed form along with any required documentation, including copies of the front and back of your health insurance card, to 1-855-398-7634.
8. After submitting, save any changes, download a copy of the completed form for your records, and ensure you follow up if you don't receive confirmation.

Complete your enrollment form online now to access your free trial of !