Follow the steps to successfully complete the Enrollment Form.

1. Click the ‘Get Form’ button to obtain the Enrollment Form and open it in your online editor.
2. Begin by filling out the prescriber information section. Input the prescriber name, email, NPI number, phone number, and address. Ensure all fields marked with an asterisk (*) are completed.
3. Next, enter the patient insurance information, including policyholder name, relationship to the patient, member ID number, group ID number, Rx BIN, PCN, and tax ID number.
4. Provide the patient information including the patient's name, date of birth, gender, and address. Make sure to list any known allergies as well.
5. Fill in the patient diagnosis section by including the diagnosis code and a description of previous treatments, including dosages, dates of therapy, and reasons for treatment failures.
6. In the prescription information section, specify the patient name, the prescribed drug (e.g., Ointment), quantity, and dosage instructions. Ensure the quantity selected is sufficient for the patient's needs.
7. At the end of the form, the prescriber needs to sign and date the form. Note that a stamped signature is not accepted.
8. Once all sections are completed, review the form to ensure accuracy. You can then save your changes, download the completed form, or print it for submission.

Start filling out your Enrollment Form online today to ensure a smooth process.