Get Inbrace Support Program

The Inbrace Support Program offers essential assistance for individuals seeking support with Ingrezza treatment. This guide provides clear, step-by-step instructions to help users complete the associated online form accurately and efficiently.

Follow the steps to complete the Inbrace Support Program form.

1. Click 'Get Form' button to access the Inbrace Support Program form and open it in the online editor.
2. Provide the patient information. Fill in the fields for first name, last name, address, city, ZIP code, social security number, state, date of birth, gender, email, and preferred contact times. Include an alternate contact or caregiver's name and phone number if applicable.
3. In the patient insurance information section, enter the medical insurance name and pharmacy insurance name. Include their phone number, group number, policy holder's name and date of birth, and any relevant policy details. Check the box if the patient does not have insurance and attach a copy of the insurance card.
4. Fill in the clinical information by entering the primary diagnosis code category and any other diagnoses. Specify any known allergies.
5. Complete the prescriber information by providing the prescriber’s name, NPI number, facility name, tax ID number, address, state, city, phone, fax, office contact name, and contact email address.
6. For the prescription for Ingrezza capsules, check the appropriate boxes for initial or maintenance prescriptions. Specify the dosage and the duration of the prescription. Ensure to include whether there are any refills.
7. If applicable, opt into the Ingrezza Start Program by authorizing the program pharmacy to dispense a free initial supply of Ingrezza. Provide details regarding the prescription and specify the quantity and refills.
8. In the prescriber certification section, ensure the prescriber signs and dates the form. Note that an original signature may be necessary based on applicable laws.
9. Once all sections are filled out, review the form for completeness. Users can save the changes made to the form, download it for their records, print a copy, or share it as required.

Complete your Inbrace Support Program form online today for the best experience.