Get Taltz Enrollment Form Pdf 2020-2025

Filling out the Taltz Enrollment Form Pdf online is a straightforward process designed to gather essential information for enrolling in the Taltz Together program. This guide will walk you through each section of the form to ensure that you provide all necessary details accurately.

Follow the steps to complete the enrollment form online:

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred PDF editor.
2. Begin by filling out the patient information section. Enter the patient's name, gender, date of birth, address, email, and primary phone number. Include the best time to contact and details of any personal representative if applicable.
3. In the insurance information section, indicate if there is no insurance coverage or attach a copy of the policyholder’s insurance card. If you have an insurance plan, complete the required fields: primary insurance name, policyholder name, and contact numbers.
4. Select the support services requested for the patient. Indicate if you need field reimbursement support or an insurance investigation, and specify any additional offerings such as injection training or sharps disposal support.
5. Provide the prescriber information by entering the prescriber's name, NPI number, practice name, address, and contact information.
6. Fill out the clinical information section, including the primary diagnosis and previous treatments, if any. Indicate any contraindications or allergies to listed treatments.
7. Complete the Taltz prescription information section if requesting insurance investigation. Fill in the device, dosing, quantity, day supply, and number of refills.
8. The prescriber must manually sign the form. Ensure the prescriber’s details, signature, and date are accurately recorded.
9. Review the completed form for accuracy. Once verified, save your changes, and prepare to submit the form.
10. Fax the signed form (front and back) to 1-844-344-8108. For questions or concerns, call Taltz Together at 1-844-TALTZ-NOW (1-844-825-8966).

Complete your Taltz Enrollment Form Pdf online today for proper enrollment in the Taltz Together program.