Get Viivconnect Enrollment Form

This guide offers detailed instructions on how to complete the Viivconnect Enrollment Form online. Following these steps will ensure that all necessary information is provided accurately to aid in accessing ViiV Healthcare medicines.

Follow the steps to complete the Viivconnect Enrollment Form seamlessly.

1. Click the ‘Get Form’ button to obtain the Viivconnect Enrollment Form and open it in your preferred editing tool.
2. Begin by selecting the services you require from the options listed. Check all that apply to your situation, such as benefit verification or co-pay program assistance.
3. In the section for ViiV Healthcare medication prescribed, enter the product name and dosage in milligrams. This information is essential for determining your needs.
4. Fill out the applicant information completely. This includes your first name, middle initial, last name, preferred phone number, date of birth, gender, address, and household details.
5. Provide your Social Security Number and total gross annual income. This information assists in eligibility verification for the program.
6. Authorize information sharing by checking the appropriate boxes regarding your consent. Make sure to read the implications of what agreeing entails.
7. If applicable, complete the shipping address section. This is important if the medication is to be sent to a different location than your primary address.
8. List any known allergies and health conditions, checking the box if there are none, to ensure your safety when receiving medication.
9. Answer the questions related to prescription coverage, indicating eligibility for state or federal programs as well as private insurance.
10. Fill out the insurance information section, ensuring to include the required details about your primary insurance provider.
11. Provide your prescriber’s information including their name, contact details, practice name, and tax ID. This data is imperative for processing your enrollment.
12. Complete the patient authorization and release section. Sign and date this section to certify the accuracy of the information provided.
13. Review the entire form for completeness and accuracy before submitting. Ensure that all required attachments, including a prescription, are included.
14. Once satisfied, save your changes, and proceed to download or print the completed form for your records, if necessary. You may also choose to share the form as required.

Complete your enrollment for ViiVConnect online today to ensure you have access to the necessary medications and assistance.