Get Assure Program Enrollment Form For Rexulti Brexpiprazole

Filling out the ASSURE Program Enrollment Form for REXULTI (brexpiprazole) online is a straightforward process that allows for efficient enrollment in the program. This guide provides clear, step-by-step instructions to assist you in completing each necessary section of the form accurately and effectively.

1. Begin by locating the 'Get Form' button to access the ASSURE Program Enrollment Form. Click this button to retrieve the form and open it for editing.
2. In the first section labeled 'Prescriber Information,' fill out all applicable fields. This includes the prescriber’s name, license number, state of licensure, facility address, and contact information. If available, provide an alternate contact as well, although this is optional.
3. Proceed to fill in the 'Patient Information' section. Enter the patient's first and last name, middle initial, date of birth, gender, and contact details. Additionally, ensure the Social Security Number is included, especially for the Patient Assistance Program.
4. Next, in the 'Prescription Information & Prescriber Authorization' section, input the primary diagnosis code, prescribed dosage, quantity, and any refills as necessary. Remember that the prescriber’s signature is mandatory even if a prescription copy is attached.
5. Complete the 'Patient Insurance Information' section by either submitting copies of the insurance cards or entering the insurance details directly into the provided fields. If the patient lacks insurance, indicate this accordingly.
6. Review the 'Patient Authorization' section, which is optional. By signing this section, the patient consents to the sharing of their protected health information necessary for program participation.
7. Once all sections are completed, ensure that all changes are saved. You may then choose to download, print, or share the form as needed.

Complete the ASSURE Program Enrollment Form online today to ensure timely processing and support.