Get 360enrollment

The 360enrollment form is essential for patients seeking support through the Access 360 program offered by AstraZeneca. This guide provides a clear, step-by-step approach to completing the form to ensure ease of submission and access to necessary support.

Follow the steps to successfully complete the enrollment form.

1. Press the ‘Get Form’ button to access the 360enrollment form and open it in your preferred editing tool.
2. Begin by filling out the 'Patient Information' section. Provide the patient's first name, last name, date of birth, gender, preferred language, address, phone numbers, email, and alternative contact details. Ensure all required fields are accurately completed.
3. Next, complete the 'Insurance Information' section. Include details from the front and back of medical and pharmacy insurance cards. Specify the type of insurance and provide the primary and secondary insurance names and subscriber IDs.
4. In the 'Clinical Information' section, include the patient's diagnosis and relevant ICD-10 code. Fill in the eosinophil count and the number of asthma exacerbations if applicable. Provide the prescriber's information, practice details, and contact information.
5. Proceed to the 'Prescription Information' section. Specify the medication prescribed, dosing details, and how the patient will obtain the medication. If necessary, complete additional details about the administering practice, if it differs from the prescribing practice.
6. Sign and date the form in the signature sections provided for both the prescriber and the patient/legally authorized representative. Make sure to verify that a valid diagnosis is indicated and that no reimbursement for the medication will be sought.
7. After all sections are filled out accurately and the form is signed, fax the completed document to 1-833-329-2360. You may need to include additional information based on the type of support requested.

Complete your 360enrollment form online today to access the support you need!