MyPRALUENT™ Enrollment Form Instructions and Details
This document provides comprehensive instructions and details for enrolling in the MyPRALUENT™ program, including benefits, patient assistance, and clinical support. It outlines the required patient, insurance, and prescriber information, as well as the steps for treatment verification and household income documentation.
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How do I fill this out?
To fill out this form, you need to provide detailed patient information, insurance details, and prescriber information. Make sure to read and agree to the patient certifications and patient authorization sections. Finally, sign and date the form where indicated and fax it to the provided number.
How to fill out the MyPRALUENT™ Enrollment Form Instructions and Details?
1
Provide patient information including name, address, and contact details.
2
Attach copies of medical and prescription insurance cards.
3
Fill in prescriber information and prescription details.
4
Complete the sections on treatment information and household income as applicable.
5
Sign, date, and fax the completed form to the provided number.
Who needs the MyPRALUENT™ Enrollment Form Instructions and Details?
1
Patients who are prescribed PRALUENT and need to enroll in the support program.
2
Healthcare providers who need to submit patient information for PRALUENT treatment.
3
Patients without insurance coverage for PRALUENT who need to apply for patient assistance.
4
Prescribers who need to authorize temporary shipments of PRALUENT during benefits determination delays.
5
Patients who need support with medication adherence and injection training.
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What are the instructions for submitting this form?
To submit this completed form, fax it to 1-844-872-5447. Ensure all required fields are accurately filled out, and include any necessary attachments such as copies of insurance cards. For additional assistance, contact MyPRALUENT at 1-844-PRALUENT (1-844-772-5836). For mail submissions, send the completed form to MyPRALUENT, 1670 Century Center Parkway, Memphis, TN 38134. It's advised to keep a copy of the submitted form for your records.
What are the important dates for this form in 2024 and 2025?
Ensure your form is submitted timely for continued support. Verification deadlines may apply. Contact MyPRALUENT for specific dates.
What is the purpose of this form?
The purpose of the MyPRALUENT™ Enrollment Form is to streamline the enrollment process for patients prescribed PRALUENT. This form gathers all necessary patient, insurance, and prescriber information to verify eligibility for various support programs, including copay assistance, patient assistance, and clinical support. By completing and submitting this form, patients can access the necessary resources and support for their PRALUENT treatment journey.
Tell me about this form and its components and fields line-by-line.
- 1. Support Requested: Section to indicate the types of support needed.
- 2. Patient Information: Fields for patient details such as name, address, contact information, and date of birth.
- 3. Insurance Information: Fields for capturing insurance details including policy numbers and insurer contact information.
- 4. Prescriber And Rx Information: Section for prescriber details and prescription information.
- 5. Treatment Information: Fields for treatment details including diagnosis codes and previous treatments.
- 6. Household Income: Section to document household income for patient assistance eligibility.
- 7. Patient Certifications: Section for patient certifications and authorizations.
What happens if I fail to submit this form?
Failure to submit this form can result in delayed or denied access to PRALUENT treatment and support programs.
- Access to Medication: Delayed or denied access to PRALUENT medication.
- Support Programs: Ineligibility for financial and clinical support programs.
- Treatment Delays: Potential delays in starting or continuing treatment.
How do I know when to use this form?
- 1. New Patient Enrollment: For new patients starting PRALUENT treatment.
- 2. Insurance Verification: To verify insurance coverage for PRALUENT.
- 3. Reauthorization: For reauthorizing treatment and support services.
- 4. Patient Assistance: To apply for patient assistance programs.
- 5. Clinical Support: To request clinical support and training for PRALUENT administration.
- 6. Bridge Program: For temporary shipments of PRALUENT during benefits determination delays.
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