Get Pharmacy Redesign Pilot Program Enrollment - Dtic

Filling out the pharmacy redesign pilot program enrollment form online can streamline your application process. This guide provides clear steps to ensure you accurately complete each section of the form for optimal results.

Follow the steps to successfully enroll in the program.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by providing sponsor information, including the name (last, first, middle), social security number, address details (street, city, state, and ZIP code), and date of birth. Complete the telephone number sections for home and work, and indicate any emergency contact information.
3. Indicate your gender by selecting either 'male' or 'female'. If you have additional health insurance, choose 'yes' or 'no'. If yes, make sure to complete the relevant sections regarding other health insurance.
4. List all eligible family members for enrollment. Include their names, social security numbers, dates of birth, relationships to the sponsor, and any other relevant contact details. If necessary, use additional pages to accommodate all family members.
5. For any family members listed with other health insurance, complete the additional health insurance section by providing the insurance company name, type of coverage, policy number, and any relevant contact information.
6. Sign the form by providing your signature and the date signed, ensuring the date is entered in the format YYYYMMDD.
7. Review all entries for accuracy, ensuring that all required fields are complete, and then save your changes.
8. Print the completed form or share it as required. Ensure to return the completed document to the appropriate address indicated on the back of the form.

Start completing your enrollment form online today for a smoother application experience.