Follow the steps to accurately complete your enrollment form.

1. Press the ‘Get Form’ button to access the enrollment form and open it in your preferred editor.
2. Begin by entering the patient information section. This includes the patient's name, date of birth, and the last four digits of their Social Security Number. Ensure all information is accurate.
3. In the prescriber information section, include the prescriber's name, DEA number, NPI, and contact details. Be sure to provide a complete address including city, state, and ZIP code.
4. Next, complete the insurance information. This requires entering the group or hospital information along with any other relevant details. If necessary, attach a copy of the patient's insurance card.
5. Fill out the medical information section thoroughly. You will need to enter the diagnosis, including the specific ICD-10 code. Make sure to note any allergies or concomitant medications.
6. In the prescription information section, specify the medication, dosage, directions for use, and quantity needed. Review that only one prescription is written per blank.
7. Complete any additional details such as the provider shipping information, including the office contact, phone number, and preferred shipping address for the medication.
8. Finally, review all sections for accuracy and completeness. You can now save the document with your changes, download, print, or share the completed form as needed.

Complete your VA Premier Sublocade Injection CIII Enrollment Form online now to ensure timely treatment.