Get Eilquis Patient Authorization And Agreement

Filling out the Eilquis Patient Authorization and Agreement online is an essential step to access reimbursement support services provided by the program. This guide offers clear, step-by-step instructions to help you complete the form accurately and confidently.

Follow the steps to successfully complete the Eilquis Patient Authorization and Agreement form.

1. Click the ‘Get Form’ button to access the Eilquis Patient Authorization and Agreement form and open it in your preferred editor.
2. Carefully read through the entire authorization section to understand how your personal information will be used and disclosed. This section includes details about what information will be collected and by whom.
3. Fill in your personal information accurately, including your contact information, date of birth, health information, and any other relevant data requested on the form.
4. Provide the names and contact information of your caretakers, such as healthcare providers, insurers, and pharmacists, who will share your information as authorized.
5. Review the purpose of the information disclosure to ensure you understand how your data will help in processing your application and providing program services.
6. Note the authorization expiry information. The authorization is effective for five years unless canceled or expired by law. Ensure you understand how to cancel if needed.
7. Complete the patient certification by confirming that the information provided is truthful and acknowledge that further documentation may be requested by the program.
8. Sign and date the form where indicated, either as the patient or a personal representative if applicable. Ensure that all necessary fields are filled out, including your printed name and contact information.
9. Once you have completed all sections of the form, save your changes and download a copy for your records. You may also choose to print or share the form as necessary.

Take the next step and complete your Eilquis Patient Authorization and Agreement online today.