Get Austedo Enrollment Form

Filling out the Austedo Enrollment Form online is a straightforward process that allows users to provide necessary information for medication enrollment. This guide will help you navigate each section of the form, ensuring that you submit all required details accurately and efficiently.

Follow the steps to complete the Austedo Enrollment Form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Start by filling in the Patient Information section. This includes facility name, phone number, full name (first, middle initial, last, suffix), date of birth, address, preferred contact number, email, allergies, previous TD medications, and concurrent medications.
3. Next, provide the Insurance Information. Attach a copy of the patient’s insurance card and pharmacy benefits card (front and back). Fill in the Pharmacy Insurance Name, Medical Insurance Name, phone numbers, ID numbers, group numbers, and policy holder's name and date of birth.
4. In the Diagnosis Code section, indicate the appropriate ICD-10 code, for example, G24.01 for Tardive Dyskinesia.
5. Complete the Austedo Prescription Information by selecting all relevant options regarding dosing schedule and the prescribed medication details, including the quantities and strengths of the medication requested.
6. Provide the Prescriber Information. Fill in the prescriber’s name, type (MD, NP, PA, DO), NPI number, office address, nurse/office contact information, phone, fax, and ZIP code.
7. Ensure the prescriber signs the form. This signature is required for prescription orders. If applicable, provide additional authorization details and ensure compliance with state-specific requirements.
8. Finally, complete the Patient Authorization section by printing the patient’s name, obtaining their signature, and noting the date. If someone else is signing, describe their legal authority.
9. Once all fields are completed and checked for accuracy, save the changes. You can then download, print, or share the completed form as needed.

Begin filling out the Austedo Enrollment Form online to ensure timely processing of your prescription.