Get Afstyla Enrollment Form

Filling out the AFSTYLA Enrollment Form online is a straightforward process designed to ensure that you receive the necessary support and therapy. This guide provides a step-by-step approach to help you accurately complete each section of the form.

Follow the steps to successfully complete the AFSTYLA Enrollment Form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Fill out the patient information including name, date of birth, social security number (last four digits), and contact details. You must also indicate the current therapy status.
3. Complete the patient insurance information section, providing details for both primary and secondary insurance, if available. Attach copies of both sides of the patient’s insurance card(s) where applicable.
4. Read and complete the authorization for release of patient health information. Sign this section to confirm the accuracy of the provided information.
5. Optionally, opt-in to receive relevant communications and patient resources from CSL Behring by signing the designated section.
6. If interested in the trial program or prescription referral, fill out the prescriber information with the clinician’s details, including licensing and contact information.
7. Provide dosing information such as patient weight, dosage, and frequency of dosing in the relevant section.
8. The prescriber must authorize treatment by signing and dating the authorization section, confirming the medical necessity for AFSTYLA.
9. Once all sections are completed, review the form for accuracy and completeness. Save your changes, and prepare to download, print, or share the completed form as necessary.

Complete your AFSTYLA Enrollment Form online today to ensure you receive the therapy you need.