Get Tremfya Enrollment Form

Filling out the Tremfya Enrollment Form is essential for enrolling in treatment and ensuring your prescription needs are met. This guide provides a detailed, step-by-step approach to assist you in completing the form accurately and efficiently online.

Follow the steps to accurately complete the Tremfya Enrollment Form.

1. Click ‘Get Form’ button to obtain the Tremfya Enrollment Form and open it in your editor of choice.
2. Fill out the patient information section with your full name, date of birth, and contact information, including preferred contact number and best times to reach you.
3. Provide your insurance information in full. This includes details about your primary medical insurance and pharmacy benefits or secondary insurance, along with the cardholder's information and policy numbers.
4. Indicate any prior therapies you have undergone, selecting from the listed treatments or specifying other medications if applicable.
5. Complete the prescription information section. Specify the details of the medication, including the diagnosis and dosage instructions. Ensure that the prescriber provides their signature to validate the prescription.
6. If applicable, enroll in the PsO Simple Trial Program by indicating whether to ship the first dose to your physician's office and filling out the requested address details.
7. Fill out the prescriber information section completely, including the prescriber's name, contact details, and relevant identification numbers.
8. Review the section on prior authorization assistance. You may check the box if you do not wish to receive assistance with this process.
9. Once you have completed all sections of the form, review the information for accuracy. Save changes to retain your entries and either download the completed form, print it, or share it as needed.

Complete your Tremfya Enrollment Form online today to ensure timely processing of your treatment registration.