Follow the steps to complete the application form efficiently.

1. Press the ‘Get Form’ button to obtain the application form and open it in your preferred editing tool.
2. Complete Section I: Patient Information. This section requires details such as the patient's name, date of birth, contact information, and household income. Ensure all mandatory fields are filled accurately.
3. Provide insurance information in Section I. Indicate any applicable insurance coverage and attach a copy of your prescription insurance card if needed. Be sure to list your total yearly household income.
4. In Section II, the licensed prescriber must fill in treatment and prescription information. Specify the medication name, dosage, ICD code, and necessary quantities. This section is crucial for the approval process.
5. Section III should be completed with the healthcare provider's shipping address. Confirm whether the patient is receiving outpatient treatment and provide accurate details to ensure the medication is sent to the correct address.
6. Both the patient and the prescriber must review pertinent agreements and consent to share information. Sign and date the Patient Agreement and Prescriber Certification, ensuring all conditions are understood.
7. Once all sections are completed and reviewed, save any changes made to the form. You can then download, print, or share the document as needed.

Complete your application online today to access the medications you need.