Get Simple 3-step Registration: Step 1 - Patient ... - Rxresource

Filling out the SIMPLE 3-STEP REGISTRATION form for the Destination Access Program is a straightforward process. This document will guide you step-by-step to ensure you complete the registration efficiently and accurately.

Follow the steps to successfully complete the registration form.

1. Press the ‘Get Form’ button to obtain the Patient Enrollment Form. This will allow you to access the document in preparation for filling it out.
2. Carefully complete all sections on Page 1 of the Patient Enrollment Form. It is essential to provide a response in every field—indicate ‘0’ or ‘NO’ if applicable to avoid any blank fields. Remember to sign and date the enrollment form. If you are unable to sign, your power of attorney can sign on your behalf; ensure you provide an explanation if the signature is not the patient’s.
3. If you are applying for free product assistance, include proof of yearly household adjusted gross income. Acceptable documents include your Federal tax return (preferred), Social Security income statement, or any relevant income statements. Make sure to include the total yearly household adjusted gross income, which can be referenced from your tax documents.
4. Once all required sections are completed, you may save changes to the form. Ensure that all information is accurate before submitting.
5. You can then download, print, or share the completed form as necessary. Ensure that you submit it via fax at (888) 776-2370 or mail it to the provided address to expedite processing.

Complete your registration form online today and ensure you receive the assistance you need.