Get Otrexup () Injection Totalcare Support Program

Filling out the Otrexup Injection TotalCare Support Program form is a crucial step for individuals seeking assistance with their medication. This guide will provide you with a clear, step-by-step approach to completing the application online, ensuring that you submit all necessary information for timely processing.

Follow the steps to complete your application accurately

1. Click 'Get Form' button to obtain the application and open it for completion.
2. Fill in your personal information, including your name, address, date of birth, and contact details. Make sure to double-check the accuracy of the information provided.
3. Indicate your gender and provide your Social Security Number (last four digits only) if applicable. Answer the questions regarding your Medicare enrollment and insurance coverage.
4. Provide the total monthly income for your household. Attach acceptable proof of income documentation, such as tax returns or pay stubs for all individuals in the household.
5. Ensure that both the patient’s signature and date are filled in the designated areas. If a representative is completing the form, their information must also be included.
6. Fill in the prescriber information section, including the prescriber’s name, contact information, and signatures. This is essential for the application to be valid.
7. Confirm that you have attached all required documentation, such as proof of income and any necessary Medicare or Medicaid information.
8. Finally, save the completed application, and prepare to fax or send it by mail to the Otrexup TotalCare Support Program using the address provided.

Complete your application online today for assistance with your Otrexup medication.