Get Contact Mulpleta Assist

This guide provides clear instructions for completing the Contact Mulpleta Assist form online. By following these steps, users can efficiently fill out the required information and submit their application with ease.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the patient information. Fill in the first name, last name, date of birth in MM/DD/YYYY format, gender, and the last four digits of the Social Security Number. Complete the address, city, state, zip code, phone number, and email if available. Select whether to ship the product to the patient’s or prescriber’s address.
3. In the prescription insurance information section, indicate whether the patient has insurance. If insurance is present, provide the required details such as the insurance name, policyholder name, member ID, Rx BIN, group ID, Rx PCN, and insurance phone number. Ensure to include copies of the front and back of the insurance card.
4. Fill out the prescriber information by entering the prescriber’s first and last name, NPI number, address, city, phone number, and state. Include the ZIP code, fax number, email, and the primary office contact's full name.
5. In the prescription information section for Mulpleta, check the box for the dosage required and provide the patient's first dosing date. Ensure the prescriber includes their signature and the date.
6. Complete the statement of medical necessity by addressing the questions regarding the prescription of Mulpleta, chronic liver disease, and thrombocytopenia. Record the patient's platelet count and test date, along with any necessary diagnosis codes.
7. For prescriber authorization, verify the accuracy of the information provided, sign the authorization section, and include the date.
8. Once all fields are accurately completed, save your changes. You can download, print, or share the completed form as necessary.

Complete the Contact Mulpleta Assist form online today!