Get Support Path Program Intake Form

Completing the Support Path Program Intake Form online is an essential step for individuals seeking assistance with their medication. This guide will provide you with clear, step-by-step instructions to ensure your form is filled out accurately and efficiently.

Follow the steps to successfully complete the intake form.

1. Click ‘Get Form’ button to access the Support Path Program Intake Form online and open it in the appropriate editor.
2. In Section 1, check all boxes that apply to the requested Support Path offerings, including benefits investigation, prior authorization and appeals information, patient assistance program eligibility screening, and co-pay coupon program enrollment.
3. In Section 2, fill in the medication requested by entering the product name and dosage in milligrams (mg). This information is required.
4. In Section 3, enter all prescriber information including the prescriber name, facility name, full address, contact numbers, NPI, tax ID, and state license number. All fields in this section are required.
5. Section 4 requires a healthcare provider to complete the patient's diagnosis and medical information. Include the diagnosis, ICD-10 code, HCV genotype, and fibrosis score, while also indicating if the patient is treatment naïve, previously treated, or currently on therapy.
6. In Section 5, provide the patient's personal information including their name, preferred language, address, date of birth, phone number, and gender. This section must also include an alternate contact name and relationship.
7. For Section 6, indicate whether the patient is insured or uninsured. If insured, fill in detailed insurance information and ensure a copy of the insurance card is attached.
8. Section 7 is only required if applying for the patient assistance program (PAP). Include the patient's current annual household income and household size. The patient must sign this section and attach documentation of all income sources.
9. Finally, in Section 8, the patient or authorized representative must sign and date the form to certify all information is complete and accurate.
10. After completing all sections of the form, save your changes. You can then either print the form or share it, and ensure to fax it to the Support Path Program at the provided number.

Experience a smooth application process by completing your Support Path Program Intake Form online today.