Get Sanofi Patient Assistance Connection & Application Form

Filling out the Sanofi Patient Assistance Connection & Application Form online can be a straightforward process when guided step-by-step. This guide aims to provide clear instructions on each section to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your application.

1. Press the ‘Get Form’ button to obtain the application form and open it in your preferred editor.
2. Begin with Section 1, 'Patient Information'. Fill in the patient’s first name, middle initial, and last name. Indicate the gender, address, city, state, zip code, cell phone number, date of birth, and social security number. Include details on primary and secondary insurance, including the policy holder's name and insurance phone numbers.
3. In Section 2, 'Diagnosis and Prescribing Information', specify the relevant diagnosis codes and the details regarding the prescribed medication. Indicate the injection site and the quantity needed, as well as any previous drug treatments.
4. Move to Section 3, 'Buy and Bill or SPP Triage Service'. Indicate your preference for either Buy and Bill or Specialty Pharmacy. If choosing Specialty Pharmacy, confirm the desire for Rx to be triaged there.
5. Complete Section 4, 'Prescriber Information'. Provide the prescriber’s name, type, state of license, NPI number, tax ID, DEA number, and any additional treating physician details if applicable. Fill in the facility name and contact information accurately.
6. In Section 5, 'Resource Connection', indicate if the Program can contact the patient regarding external resources. Check interests in possible resources such as clinical support services, transportation, and advocacy support.
7. Finish with Section 6, 'Patient Assistance Connection'. Provide the total number of people in the household and annual household income. Review the income verification details, authorization, and necessary signatures for both the patient and prescriber where required.
8. Once you have filled in all sections, you can save your changes, download, print, or share the completed form as needed.

Complete your Sanofi Patient Assistance Connection & Application Form online today to ensure you receive the support you need.