Get Flex Forward Enrollment Form

Completing the Flex Forward Enrollment Form online is a straightforward process that helps facilitate your access to important health services. Follow this guide to ensure that all required information is accurately provided.

Follow the steps to successfully complete the enrollment form.

1. Click ‘Get Form’ button to obtain the enrollment form and open it in your preferred editor.
2. Begin with the patient information section. Fill in the last name, first name, address, city, state, ZIP code, phone numbers, email address, gender, date of birth, and Social Security Number for insurance verification purposes.
3. Proceed to the prescriber information. Include the last name, first name, NPI number, state license number, tax ID number, DEA number, office name, address, phone number, and fax number. Also, provide details for the primary contact including their last name, first name, title, email, phone number, and fax number. Select the preferred method of contact.
4. In the insurance information section, indicate if the patient is uninsured. If insured, attach a copy of the insurance card and fill out the required details including plan names, ID numbers, group numbers, policy holders, and relationships.
5. Complete the diagnosis and clinical information. Select the appropriate ICD-10 code and injection-site location. Document any previous treatments the patient has undergone and note any known drug allergies.
6. In the prescription information section, specify the quantity and directions for the administration of ZILRETTA. Make sure to attach a separate prescription if additional documentation is needed.
7. Authorize the physician’s signature, certifying the medical necessity of the therapy and allowing relevant information to be shared with the necessary parties. Ensure the date is included.
8. Complete the patient authorization section, providing the patient’s name and date of birth, and have them sign to authorize the release of their protected health information.
9. After filling out all sections, review the completed form for accuracy. Save all changes before proceeding.
10. Finally, you can download, print, or share the completed form as needed, and fax it to the provided number.

Start completing your Flex Forward Enrollment Form online to ensure prompt processing of your application.