Follow the steps to successfully complete the Xelsource Enrollment Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the patient information section, where you will enter the patient's name, date of birth, and address. Ensure all details are accurate for successful processing.
3. Fill in the primary phone number along with alternative contact details. Specify the best times to reach the patient.
4. Complete the insurance section by providing information about the patient's primary and secondary prescription coverage, including policy ID numbers and the relationship of the policyholder to the patient.
5. In the patient authorization section, review the permissions being granted regarding the sharing of protected health information. Ensure to check the relevant boxes as needed.
6. Enter prescriber information, including the prescriber's name, specialty, NPI number, and contact details.
7. Provide clinical information, including diagnosis date, current medications, and any relevant allergies or prior adverse reactions to medications.
8. Finally, review the prescription information section, confirming that the prescribed medication, dosage, and refill instructions are correct before signing.
9. Once all sections are completed, save your changes, download the completed form, and print or share it as necessary.

Complete the Xelsource Enrollment Form online today to ensure a smooth enrollment process.