Follow the steps to successfully complete your application for financial assistance

1. Press the ‘Get Form’ button to access the Velphoro Financial Assistance form and open it in the editor for completion.
2. In Section 1, enter the patient’s information, including their first name, last name, social security number, address (ensure it is a residential address and not a P.O. Box), date of birth (confirm they are 18 or older), and gender. Additionally, indicate if the patient is currently on dialysis.
3. Move to Section 2 and provide the patient's insurance information. Attach readable copies of both sides of the insurance cards. Select the appropriate insurance type and fill in all required fields, including insurance company name, member ID, and policy holder information.
4. For Section 3, input the prescriber and dialysis facility details. This information includes names, addresses, contact details, and relevant practice numbers. Make sure to provide all necessary identifying information as required.
5. If you are completing the form for benefit verification, proceed to Section 4 and input any required prescription information, including the diagnosis code, laboratory values, and prescribed medications. Ensure the accuracy of the dosing information listed for Velphoro or any other medications.
6. In Section 5, sign the authorization for benefit verification. This signature can come from either the healthcare provider or the patient. Ensure that the form is signed as it cannot be processed without an appropriate signature.
7. If applying for the Patient Assistance Program (PAP), continue to complete Sections 6, 7, and 8 as applicable, along with additional required signatures.
8. Once you have completed all relevant sections, review the form for any errors or missing information. After verification, you can save changes, download a copy, and print it for your records or fax it to the provided number.

Complete your Velphoro Financial Assistance form online today to access critical support.