AUBAGIO One to One Start Form for Support Services
This AUBAGIO One to One Start Form provides essential instructions for patients and prescribers to access support services. It outlines steps for authorization and information sharing related to AUBAGIO therapy. Ensure proper completion for eligibility in the support programs.
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How do I fill this out?
Filling out the AUBAGIO Start Form is a straightforward process. Begin by reading the service descriptions and authorizations carefully. Gather necessary documents and complete the form accurately to ensure a smooth submission.
How to fill out the AUBAGIO One to One Start Form for Support Services?
1
Have your patient read the overview and sign the required sections.
2
The prescriber completes the remaining parts of the form.
3
Attach copies of the patient’s insurance and pharmacy benefit cards.
4
Fax the completed form to the designated number.
5
Await a call from a One to One Nurse for further assistance.
Who needs the AUBAGIO One to One Start Form for Support Services?
1
Patients prescribed AUBAGIO who need support services.
2
Prescribing physicians who need to complete the start form for patients.
3
Care partners seeking assistance with AUBAGIO therapy.
4
Individuals looking for co-pay assistance programs.
5
Healthcare providers wanting to facilitate access to support services.
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2
Make necessary edits directly on the PDF.
3
Review your changes to ensure accuracy.
4
Save the edited document once satisfied with the changes.
5
Download or print the updated form for submission.
What are the instructions for submitting this form?
To submit the completed 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. For any inquiries, call the general support at 1-855-676-6326. Ensure all necessary sections are filled out to expedite the review process.
What are the important dates for this form in 2024 and 2025?
Currently, no specific important dates are noted for the AUBAGIO One to One Start Form in 2024-2025. Patients and providers should monitor any updates provided by Sanofi Genzyme.
What is the purpose of this form?
The purpose of the AUBAGIO One to One Start Form is to initiate the enrollment process for patients seeking support services. It includes authorizations necessary for sharing health information and verifying insurance. By completing this form, patients can access tailored services and support specific to their condition.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Contains personal details to identify the patient and their treatment.
- 2. Prescriber Information: Includes details of the healthcare provider prescribing AUBAGIO.
- 3. Insurance Information: Collects details regarding the patient's insurance plans.
- 4. Authorization Sections: Sections where the patient and prescriber grant permission to share health information.
What happens if I fail to submit this form?
If the AUBAGIO Start Form is not submitted correctly, patients may not gain access to the necessary support services. Delays in authorization or missing information may result in the inability to verify insurance promptly. This can hinder the overall timeline for the patient receiving their medication.
- Delayed Access: Incomplete forms can result in delayed services and support.
- Insurance Verification Issues: Missing or incorrect insurance information can lead to complications in verification.
- Lack of Communication: Failure to submit could lead to unclear communication from healthcare providers.
How do I know when to use this form?
- 1. Starting AUBAGIO Treatment: Patients should fill this form upon initiation of therapy.
- 2. Requesting Support Services: Use this form to access tailored support and guidance.
- 3. Insurance Verification: Necessary for confirming insurance benefits during treatment.
Frequently Asked Questions
How do I fill out the AUBAGIO Start Form?
Follow the instructions to complete the form accurately, ensuring all necessary information is provided.
Can I edit the PDF after downloading?
Yes, you can edit the PDF on PrintFriendly before downloading it.
What should I do if I have questions about the form?
For any questions regarding the form, call the provided support number for assistance.
How do I submit the filled form?
You can fax the completed form using the designated fax number.
What happens after I submit the form?
You will be contacted by a One to One Nurse for further follow-up.
Do I need to sign the form?
Yes, both the patient and prescriber need to sign the form before submission.
Is the One to One support available for everyone?
One to One support services are available to eligible AUBAGIO patients.
Can family members fill out the form for the patient?
While the patient must authorize it, family members can assist them in filling out the form.
How long does it take to receive a response?
Typically, a One to One Nurse will contact you within 2-3 business days.
Where can I find additional information about AUBAGIO?
Visit AUBAGIO.com or speak with your healthcare provider for more details.
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