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How to use or fill out the For Patients To Complete online
This guide provides comprehensive instructions for users on how to fill out the For Patients To Complete form online. Following these steps will ensure that all necessary information is accurately provided for enrollment in the LEMTRADA Support Services.
Follow the steps to successfully complete the form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Carefully read the One to One Support Services description and the authorizations provided in the initial pages of the form. This information is essential for understanding the services available.
- In the patient information section, fill out your name in the format of Last name, First name, and provide your date of birth in MM/DD/YYYY format. Specify your gender by selecting either 'Male' or 'Female'.
- Complete your address details including street address, city, state, and ZIP code. Provide your email address if you wish to receive communications electronically.
- In the contact information section, include your home and cell numbers. Indicate your preferred number for communication and whether it is okay to leave a message.
- Select the therapies that you have used in the past from the provided list by placing a checkmark next to each applicable therapy, indicating which one you used most recently.
- Sign the Patient Services Enrollment section to agree to the terms outlined on page 3, and write the date of your signature.
- In the authorization section for sharing health information, read the content carefully and provide a signature to authorize the relevant disclosures. Enter your most recent therapy's start and stop dates if applicable.
- If filling out the form as a patient representative, ensure to include your name and relationship to the patient.
- Healthcare providers must fill out their information in the prescriber section including name, NPI number, and contact details.
- Determine whether to participate in the Central Lab Program by indicating 'Yes' or 'No'. If 'Yes', specify where samples will be collected.
- After all sections are completed, save any changes to the form and choose to download, print, or share it as necessary before submitting.
Complete the For Patients To Complete form online today to ensure your enrollment in the support services.
Completed Patient means any Qualified Patient who completes the Study and who, by reason of Protocol adherence and the completeness and accuracy of the data contained in the case report form ("CRF") can be included in the pool of cases whereby the clinical efficacy and safety of Study Drug may be assessed.