Get Ingrezza Treatment Form

Completing the Ingrezza Treatment Form online is a straightforward process designed to gather essential information for your treatment. This guide will provide you with a step-by-step approach to ensure that all necessary fields are accurately filled out and submitted.

Follow the steps to complete the Ingrezza Treatment Form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Provide patient information including their name, address, date of birth, and a preferred contact number. This section is crucial as it identifies the individual receiving treatment.
3. Enter the patient's insurance information. Attach a copy of the insurance card if applicable, or check the box indicating that the patient does not have insurance.
4. Fill out the clinical information section. Indicate the primary diagnosis code for tardive dyskinesia and any other relevant diagnoses. Ensure that this information is accurate as it is vital for proper treatment administration.
5. Complete the prescription section by checking the appropriate boxes for initial or maintenance prescriptions and writing the dosage information as instructed.
6. Provide prescriber information, including the prescriber’s name, contact details, and any required identification numbers.
7. If applicable, indicate participation in the Ingrezza Start Program for a free trial supply. Ensure the relevant boxes are checked.
8. Review the entire form for accuracy. Make sure to sign and date the consent sections where required.
9. Finally, save your changes, and you may download, print, or share the completed form as needed.

Begin completing your Ingrezza Treatment Form online today!