Get 60-day Free Trial Form For (). Specifically For Starting Your Patient On The

Completing the 60-Day Free Trial Form for ® is a critical step in starting your patient on this treatment. This guide provides a clear, step-by-step process to assist you in filling out the form accurately and efficiently.

Follow the steps to successfully complete the trial form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling in the patient information section. Ensure all fields are completed to prevent delays. Input the patient's first name, middle initial, last name, email address, last four digits of their Social Security number, and contact information, including both preferred and alternate phone numbers.
3. Next, complete the insurance information section. Provide details about the patient's prescription drug insurer, group number, and the pharmacy's contact information. Fill in the patient's date of birth, sex, state, ID number, zip code, BIN number, and PCN number if applicable.
4. In the patient authorization section, ensure the patient or their representative signs to authorize communication regarding the patient's health and prescription information.
5. Provide the prescriber's information, including name, specialty, practice name, phone number, and address. The prescriber must also sign and date the prescription request to confirm it is medically necessary.
6. Document clinical information, such as the diagnosis, patient's EDSS score, and any medications they are taking. The prescriber should also specify if the patient has a history of seizures or renal impairment.
7. Finally, review the completed form for accuracy. Save your changes, and use the options to download, print, or share the form as needed.

Complete the 60-Day Free Trial Form for ® online today for your patient’s benefit.