Follow the steps to successfully complete your enrollment form.

1. Click ‘Get Form’ button to access the enrollment form and open it for editing.
2. Begin by filling out the patient information section, including first name, middle initial, last name, and contact information such as street address, city, state, zip code, and phone number. Be sure to include the patient's date of birth and gender.
3. Provide alternate contact or caregiver information, ensuring you list their name, phone number, and relationship to the patient. Indicate whether you have the patient's consent for the program to contact the caregiver by selecting 'Yes' or 'No.'
4. In the insurance information section, indicate if the patient is insured by selecting 'Yes' or 'No.' If insured, fill out the primary and secondary insurance information, including the name of the insurance company, policy number, policyholder details, and group number.
5. Complete the medication and coding information by checking the medications prescribed to the patient. Refer to the provided J-code for accurate entry.
6. Fill in the prescriber information, including the prescriber’s name, state where licensed, and NPI number. Include facility details and primary contact information.
7. Ensure that the healthcare provider (HCP) declaration section is completed by obtaining the necessary signature and date from the prescriber.
8. Obtain the patient's consent and release of information signature. If a legal representative is signing, they must provide their relationship to the patient.
9. Finally, review the entire form for accuracy, then save your changes, download, print, or share the completed form as needed.

Complete your enrollment form online today to access Amgen Assist 360 services.