Get Enrollment Form Page 1 Of 3 - Vemlidy

Filling out the enrollment form for VEMLIDY online is an essential step to access necessary services and medications. This guide provides a clear overview of each section of the Enrollment Form Page 1 of 3, helping you navigate the process with confidence.

Follow the steps to complete the enrollment form successfully.

1. Click the ‘Get Form’ button to obtain the enrollment form and open it for editing.
2. In section 1, check all boxes that apply for the requested patient services, such as benefits investigation or prior authorization.
3. Move to section 2 and enter the prescribed Gilead medication’s product name and dosage in milligrams. If you are requesting ®, indicate the purpose for treatment or PrEP.
4. In section 3, provide the patient's information, including full name, preferred language, address, city, state, zip code, phone number, last four digits of the social security number, email, date of birth, gender, and alternate contact details.
5. Proceed to section 4 to fill in the insurance information. State if the patient is insured or uninsured and provide applicable insurance details, including attaching a copy of the insurance card if insured.
6. Complete section 5 with prescriber information, including name, facility, address, contact information, and any relevant identifiers such as tax ID and state license number.
7. Section 6 requires a healthcare provider to complete the diagnosis, including the necessary ICD-10 code.
8. In section 7, the prescriber must sign and date the form to certify the medical necessity of the prescribed medication.
9. Section 8 requires the patient or their representative to authorize the use and disclosure of personal health information by signing and dating it.
10. If applying for the Patient Assistance Program in section 9, provide the household income, number of people in the household, and submit necessary documentation.
11. Review the completed form for accuracy, then save changes or download, print, or share the form as needed.

Complete your enrollment form online today to access the necessary support and resources.