Get Sanofi Patient Connection Application March 2018 Admelog.docx

Filling out the Sanofi Patient Connection Application March 2018 ADMELOG.docx online is a straightforward process designed to assist users in accessing patient assistance for necessary medications. This guide will provide you with a clear and supportive step-by-step approach to completing the application effectively.

Follow the steps to fill out the application form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the patient information section. Input the first name, middle initial, last name, address, city, state, zip code, date of birth, gender, phone number, email address, and social security number. If the patient does not have insurance, indicate this in the designated field.
3. Proceed to the treatment and prescribing information section. Here, provide details about the medication including the drug name, ICD code, prescription details, quantity, and refills.
4. Complete the prescriber information section. Include the prescriber's name, type, state license number, NPI number, facility name, and address. Ensure that the prescriber’s signature is provided in this section.
5. In the resource connection section, indicate whether the patient would like the program to contact them about additional resources. Select any specific resources that may be of interest.
6. Fill out the patient assistance connection section. Provide the total number of people in the household and annual household income. Sign and date this section to certify that the information provided is accurate.
7. Finally, ensure that all sections are completed, including any needed signatures and HIPAA consent. Review the application checklist provided at the end of the form to confirm all information is correct.
8. After completing the form, you can save your changes, download the completed document, print it for your records, or share it as needed.

Complete your Sanofi Patient Connection Application online today to access the assistance you need.