Get Gateway Enrollment Form

Filling out the Gateway Enrollment Form online is a critical step in accessing necessary medical treatments and support. This guide will provide you with step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by checking all the services requested that apply to your situation, such as benefits verification or co-pay assistance.
3. Fill out the patient information section, including the last name, first name, date of birth, address, and contact details. Ensure the primary phone number and email address are accurate.
4. Complete the insurance information section. Provide details for both primary and secondary insurance, including the insurance names, policy IDs, group numbers, and policyholder information.
5. In the diagnosis and treatment section, specify the prescribed dosing regimen of , including dose, frequency, and diagnosis if applicable.
6. Enter the physician information, including the prescriber’s name, practice name, specialty, and contact details. Specify if you or an office is administering the medication.
7. Indicate if you are interested in obtaining medication through a specialty pharmacy and list any preferred pharmacies if applicable.
8. Review the prescriber declaration section. The prescriber must certify the prescription and sign the form.
9. Patients or legal guardians must complete the patient authorization and release section. Sign and date the authorization provided in this section.
10. If applicable, fill out the information for the patient assistance program and provide verification of household income.
11. Check the box to receive educational support if desired, and provide an email address for communication.
12. After reviewing all entries for accuracy, save the changes. You can download, print, or share the completed form as needed.

Complete your Gateway Enrollment Form online today to access the support you need.