Get Central Enrollment Form

Filling out the Central Enrollment Form online is a crucial step in accessing the Central Patient Support Program. This guide provides clear instructions to help you complete each section accurately, ensuring a smooth enrollment process.

Follow the steps to successfully complete the Central Enrollment Form.

1. Click ‘Get Form’ button to acquire the form and open it in your chosen online editor.
2. Begin by entering your patient information in the designated fields. Provide your first name, last name, and date of birth in the specified format (MM/DD/YYYY).
3. Indicate your sex by selecting either 'M' for male or 'F' for female. Proceed to fill in your address, city, state, and ZIP code.
4. Input your home phone and cell phone numbers. Additionally, provide your email address. You will also need to confirm if it is acceptable to leave a message on your home or cell phone and if the caregivers can be spoken to.
5. In the 'Prior Treatment History' section, select the medications you have previously used from the checkboxes provided. You may include others in the 'other' field.
6. Complete the pharmacy insurance information section by attaching a copy of your insurance card's front and back. Fill in the prescriber information, including their first name, last name, address, and contact information.
7. If the pharmacy insurance information is not available, complete the medical insurance information section. Attach a copy of your insurance card as required and provide your insurer's name and contact information.
8. Review the 'Patient Authorization' section. Ensure that you read and agree to the terms, sign and date where required, and input any necessary subscriber information and relations.
9. Finally, once all fields are complete and verified, you can save changes, download, print, or share the completed form as needed.

Complete your Central Enrollment Form online today to access the support you need.