Get For Additional Assistance, Call

This guide provides a clear and supportive approach to filling out the For Additional Assistance, Call form. By following the steps outlined, users will be able to successfully complete the form with ease.

Follow the steps to effectively fill out the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling out the patient information section. Provide the patient's first and last name, date of birth, gender, and address, including the city, state, and ZIP code. Specify if the patient is a resident of the United States and include their email address and preferred phone number.
3. Complete the insurance information section. Attach a copy of the patient's insurance card(s) if available, or fill out the relevant insurance details, including the prescription drug plan name, and indicate if the patient has no insurance.
4. For clinical information, confirm the patient's diagnosis by checking the appropriate box and list any known allergies.
5. In the prescriber information section, fill in the prescriber's name, address, phone number, and pertinent identification numbers. Include the office contact name and email.
6. Review the prescribing instructions for GOCOVRI capsules. Ensure to check the boxes for both initial and maintenance prescriptions as applicable, and specify any recommended dosing.
7. Sign the form where indicated, confirming agreement to receive any marketing information and educational materials as necessary. Provide the date of signature for both patient and prescriber.
8. Once all fields are completed, save changes, and utilize the options to download, print, or share the completed form as needed.

Start your digital document management journey today by completing the form online.