Get Start Form

Filling out the Start Form online for is a straightforward process that requires careful attention to detail. This guide will provide you with a step-by-step approach to ensure all necessary information is accurately entered, facilitating the support you need.

Follow the steps to successfully complete the Start Form.

1. Press the ‘Get Form’ button to obtain the Start Form and open it in your online editor.
2. Begin with the patient information section. Enter the required details including the patient's full name, date of birth, gender, and contact information. Ensure that all fields marked in blue are filled out accurately.
3. Proceed to the prescriber information section. Fill in the details for the prescriber including their name, license number, and contact information. All fields highlighted in green must be completed.
4. Move to Section I(a) to provide authorization for One to One Support Services. Carefully read the authorization statement and have the patient sign where indicated.
5. In Section I(b), read and provide consent for the authorization to share health information. Ensure that the patient signs and dates the section.
6. Complete the insurance details by providing copies of the front and back of the patient's insurance and pharmacy benefit cards. Fill in the policy numbers and group numbers as required.
7. Fill out the treatment and prescribing information indicating the medications prescribed, dosage, and preferred quantity. Make selections for medication strength and refills as applicable.
8. If applicable, indicate whether the patient qualifies for One Start® prescriptions and complete Section VI by confirming this authorization.
9. After filling out the entire form, review it for accuracy. Ensure no sections are left incomplete as this may delay processing.
10. Finally, save your changes, download a copy of the complete form, and fax the filled form along with the insurance cards to 1-855-557-2478.

Start completing your forms online today to ensure timely support and treatment!