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How do I fill this out?
Filling out the AUBAGIO Start Form is straightforward. Begin with reading the overview and authorization sections to understand the support services available. Ensure you have all necessary information ready for your healthcare provider to complete the remainder of the form.
How to fill out the AUBAGIO One to One Start Form Instructions?
1
Review the One to One Support Services overview.
2
Sign the authorization sections of the form.
3
Provide your insurance and pharmacy benefit cards to your doctor.
4
Ensure your doctor completes and faxes the form.
5
Await a call from a One to One Nurse for further assistance.
Who needs the AUBAGIO One to One Start Form Instructions?
1
Patients looking to access AUBAGIO support services.
2
Healthcare providers completing patient intake forms.
3
Pharmacists verifying patient eligibility for co-pay assistance.
4
Insurance coordinators processing claims for AUBAGIO.
5
Care partners seeking to understand available services.
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What are the instructions for submitting this form?
To submit the AUBAGIO One to One Start Form, fax it to 1-855-557-2478, or mail it to One to One Support Services, PO Box 220790, Charlotte, NC 28222-0790. Ensure that all fields are completed accurately before submission. For further inquiries, contact 1-855-676-6326.
What are the important dates for this form in 2024 and 2025?
Important dates for this form include initial enrollment deadlines and annual eligibility reviews. For 2024, ensure you access support services timely to avoid lapses. In 2025, be aware of any new legislative changes that may affect services.
What is the purpose of this form?
The purpose of the AUBAGIO One to One Start Form is to facilitate patient enrollment in support services for those prescribed AUBAGIO. This form gathers essential information to help healthcare providers assist patients effectively. Additionally, it ensures that patients can access important resources to manage their treatment.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Collects data regarding the patient's identity and contact information.
- 2. Insurance Details: Records information about the patient's insurance provider and coverage.
- 3. Prescriber Authorization: Requires a signature from the prescriber to authorize services.
- 4. Patient Authorization: Patient signature authorizing the sharing of health information.
- 5. One to One Support Services: Details the specific services the patient wishes to enroll in.
What happens if I fail to submit this form?
Failure to submit this form may lead to the patient missing out on essential support services. This can result in delayed access to medications and financial assistance. Patients should ensure timely submission to avoid interruptions in their care.
- Delayed Support: Without submission, patients may not receive timely assistance.
- Medication Access Issues: Delays could prevent access to necessary medications.
- Financial Assistance Gaps: Incomplete forms may result in missed financial support opportunities.
How do I know when to use this form?
- 1. New Patient Enrollment: Utilize the form for patients enrolling in AUBAGIO for the first time.
- 2. Insurance Verification: Employ the form to verify insurance coverage for AUBAGIO.
- 3. Accessing Support Services: Patients can use the form to access any related support services offered.
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