NORD Patient Assistance Re-Enrollment Form
This file contains the NORD Patient Assistance Re-Enrollment Form, designed for individuals applying for or reapplying to patient assistance programs. It includes sections for personal information and consent. Complete this form accurately to ensure eligibility for assistance.
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How do I fill this out?
Filling out the NORD Patient Assistance Re-Enrollment Form is straightforward. Begin by providing your personal contact information. Follow with insurance details and ensure you have included all necessary signatures.
How to fill out the NORD Patient Assistance Re-Enrollment Form?
1
Gather all required personal and insurance information.
2
Complete the application form, ensuring all sections are filled.
3
Review the form for accuracy and completeness.
4
Sign the form, either digitally or by hand.
5
Submit the completed form by the specified deadline.
Who needs the NORD Patient Assistance Re-Enrollment Form?
1
Patients applying for assistance under the NORD program.
2
Guardians or parents of patients who need help with enrollment.
3
Healthcare providers assisting patients with financial aid forms.
4
Individuals seeking to verify their existing assistance status.
5
Stakeholders monitoring patient assistance programs.
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1
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2
Select the edit option to enable editing mode.
3
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4
Review all edits to ensure accuracy and completeness.
5
Save the edited form for submission.
What are the instructions for submitting this form?
To submit the NORD Patient Assistance Re-Enrollment Form, please send it to the address below: NORD Patient Assistance Re-Enrollment, 55 Kenosia Avenue, Danbury, CT 06810. You can also fax it to (800) 999-6673 or send an email with your documents to assistance@rarediseases.org. Make sure to review your submission to avoid any errors and ensure timely processing.
What are the important dates for this form in 2024 and 2025?
Important dates for the NORD Patient Assistance Re-Enrollment Form include the application deadline of December 6, 2019, for the 2020 calendar year. Future years may have similar deadlines, typically in early December. Stay updated by checking NORD's official website.
What is the purpose of this form?
The primary purpose of the NORD Patient Assistance Re-Enrollment Form is to ensure patients have the necessary financial support for treatments. This form allows the organization to assess eligibility and streamline the re-application process. It plays a crucial role in connecting patients with essential resources for managing rare disorders.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Name of the patient applying for assistance.
- 2. Address: Current mailing address for the patient.
- 3. Email: Contact email for communications.
- 4. NORD Patient ID: Unique identifier for the patient's previous applications.
- 5. Date of Birth: Birthdate of the patient.
- 6. Program Applying To: Name of the program for which assistance is requested.
- 7. Prescribing/Treating Physician: Information regarding the physicians involved in the patient's treatment.
- 8. Insurance Benefits Information: Details of current insurance coverage related to the patient's care.
- 9. Financially Responsible Party: Who is responsible for the financial obligations related to the patient's care.
- 10. Annual Household Income: Income reported on the most recent Federal Tax Return.
What happens if I fail to submit this form?
If this form is not submitted, the patient may lose eligibility for the NORD assistance program. Delays in submitting the form can lead to interruptions in financial support for necessary treatments. Incomplete forms may result in denial of assistance.
- Financial Aid Delays: Failure to submit may postpone the financial aid required for treatments.
- Loss of Eligibility: Not submitting may lead to losing assistance from the NORD program.
- Treatment Delays: Unprocessed applications may delay access to necessary medical services.
How do I know when to use this form?
- 1. Annual Re-Enrollment: Use the form to reapply for financial assistance each year.
- 2. Update Information: Submit the form if there are changes in personal or financial circumstances.
- 3. Eligibility Verification: Utilize this form to confirm eligibility for ongoing assistance.
Frequently Asked Questions
What is the NORD Re-Enrollment Form?
The NORD Re-Enrollment Form is needed for patients reapplying for assistance from the National Organization for Rare Disorders.
How do I fill out the form?
Fill out the personal and insurance information, ensuring accuracy before submission.
Can I edit the PDF file?
Yes, you can edit the PDF directly using the PrintFriendly editor.
How do I share the PDF after editing?
You can share it via email or directly to healthcare providers.
Is there a deadline for submission?
Yes, the completed form must be returned by the specified deadline.
How do I sign the PDF?
Utilize the PrintFriendly platform's signature feature to sign your document.
What if I make an error on the form?
You can edit the form again using the PrintFriendly editor before submission.
Who should use this form?
Patients and guardians seeking financial assistance for treatment.
What if I have questions about the form?
You can reach out to NORD for assistance with the application process.
Will I receive confirmation after submitting?
You should receive confirmation once your application is processed.
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