Get Rheumatoid Arthritis Enrollment Form - Curascript

The Rheumatoid Arthritis Enrollment Form from CuraScript is an essential document for managing medication and care for individuals with rheumatoid arthritis. This guide provides clear and concise instructions to assist you in completing the form efficiently and accurately.

Follow the steps to successfully fill out the form.

1. Click 'Get Form' button to obtain the form and open it in your chosen editor.
2. Begin with the 'Patient Information' section. Fill in the patient's name, address, city, state, and zip code. Ensure that the date of birth is entered in the specified format (mm/dd/yyyy). Provide two phone numbers for the patient and list any known allergies and health conditions. Indicate the expected start date for treatment.
3. Next, fill in the 'Statement of Medical Necessity' section. Provide details regarding the primary diagnosis and include any relevant medical information such as patient weight, history of other DMARDs, and laboratory results (e.g., ESR, CRP). Document the number of tender and swollen joints.
4. In the 'Drug Delivery Information' section, indicate the preferred method of medication delivery—choose among in-office delivery, home delivery for self-injection, home health administration, or other options. Provide the necessary contact details for the delivery.
5. Complete the 'Insurance Information' section. You may either fill this out directly or fax a copy of the patient’s insurance card. Ensure you include both primary and secondary insurance details, including the group number, Rx drug card number, and RX PCN.
6. Fill out the 'Doctor/Prescriber Information' section. This requires the prescriber’s name, address, office contact information, NPI number, DEA number, and fax number where relevant. Remember that the NPI number is mandatory for all forms.
7. Complete the prescription (Rx) information by indicating the date, drug name, form, strength, quantity, directions for use, and number of refills. Provide the prescriber’s signature as required, ensuring that the signature is original and not stamped.
8. Finally, review the completed form for accuracy. Once verified, you can save the changes, download, print, or share the form as necessary.

Start filling out your Rheumatoid Arthritis Enrollment Form online now to ensure timely processing and care.