Get Sandoz One Source Enrollment Form

Filling out the Sandoz One Source Enrollment Form is a crucial step for healthcare professionals to ensure patients receive the appropriate support and resources. This guide provides clear instructions for each section of the form to streamline the online enrollment process.

Follow the steps to effectively complete the SANDOZ ONE SOURCE ENROLLMENT FORM

1. Click the ‘Get Form’ button to access and open the Sandoz One Source Enrollment Form in your preferred editor.
2. Begin with Section 1: Patient Information. Enter all relevant details about the patient, including name, address, date of birth, gender, and contact information. Note that the Social Security number is required only for Patient Assistance Program requests.
3. Move to Section 2: Insurance Information. Fill in the patient's primary and secondary insurance details, if applicable. To simplify this step, you may attach a copy of the front and back of the insurance card(s). If your patient has no insurance, check the 'No Insurance' box.
4. Proceed to Section 3: Treatment & Prescription Information. Provide the name of the medication, treatment details, and attach a prescription if necessary. Ensure to include an on-label diagnosis code and both primary and secondary ICD/Dx if required.
5. In Section 4: Prescriber Information, enter the prescribing healthcare provider's details, including their contact information and specialty.
6. Complete Section 5: Patient Authorization & Signature. Ensure the patient signs to authorize the disclosure of their medical information as needed.
7. In Section 6: Prescriber Authorization, the prescriber must sign to verify that the therapy is medically necessary and confirm a copy of the form has been provided to the patient.
8. Skip Section 7 if applying for the Patient Assistance Program. If applying for the Commercial Co-Pay Program, ensure the patient signs this section for consent.
9. If applying for the Patient Assistance Program, complete Section 8: Patient PAP Consent/Signature & Financial Info. This section includes household information and income verification details. Sign as required.
10. After filling out all relevant sections, review the form for accuracy. Users may then save changes, download, print, or share the completed enrollment form.

Take the next step in securing benefits for your patients by completing the Sandoz One Source Enrollment Form online today.