Get Novo Nordisk Patient Assistance Program Refill/reorder Request 2019-2025

The Novo Nordisk Patient Assistance Program Refill/Reorder Request form is essential for healthcare practitioners to assist patients in obtaining necessary medications. This guide provides step-by-step instructions on how to complete this form online, ensuring that all relevant information is accurately submitted.

Follow the steps to complete the refill/reorder request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the applicant information section, which includes the patient’s name, date of birth, patient ID number (if available), and patient’s state. Ensure that this section is completely filled out.
3. In the licensed health care practitioner information section, enter the state license number, practitioner’s name, expiration date, professional designation, NPI number, and shipping address including city, state, and zip code. Provide the practitioner’s phone and fax numbers, along with an optional email address.
4. Complete the order information section by specifying the product name, the maximum dose per day, and detailed sig/directions for use. If applicable, select the needle information by checking one of the available options.
5. Carefully read the health care practitioner declaration. This section requires the practitioner’s signature for verification and agreement to the terms outlined. Ensure not to use photocopies or stamps for the signature.
6. Indicate the date of signature in the designated field.
7. Review all entered details to ensure accuracy and completeness. After confirming that all sections are filled correctly, save any changes made to the form.
8. Download, print, or share the completed form as required. Remember, the form must be submitted directly by the health care practitioner along with a cover letter or HCP letterhead.

Take the next step and fill out the Novo Nordisk Patient Assistance Program Refill/Reorder Request form online today.