Get Patient Prescription Financial Assistance Form 8-11 V1

Filling out the Patient Prescription Financial Assistance Form 8-11 V1 online can streamline the process of obtaining necessary prescription assistance. This guide provides clear, step-by-step instructions to help you navigate the form efficiently.

Follow the steps to complete the form accurately and effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by entering the physician information. Include the physician's name, practice name, street address, city, state, ZIP code, office contact phone number, and fax number. Make sure to provide the office contact email and NPI number as well.
3. Fill out the patient insurance information section. Provide details such as the patient's insurance plan, insurance card copy (front and back), Medicare supplement plan ID, Medicare/Medicaid ID if eligible, and the prescription's Rx BIN, PCN, and group number.
4. In the patient information section, enter the patient's name, address, date of birth, gender, height, weight, and multiple contact numbers (home, cell/work). Include the patient diagnosis and any known allergies.
5. Complete the prescription section with all necessary details or attach a copy of the prescription. Make sure to note the refills required.
6. After filling out the entire form, review all the information for accuracy. Then, ensure that the physician signs and dates the form before submitting.
7. Finally, fax the completed form to the designated number. You should receive an email or fax confirmation of receipt. If you do not receive confirmation, check for any faxing errors.
8. If needed, contact the provided support number to verify the status of the order.

Complete your documents online today to access prescription financial assistance.