OCREVUS Start Form - Patient Enrollment Instructions
The OCREVUS Start Form provides crucial instructions for enrolling in Genentech support services. Patients can apply for free medicine, share necessary information, and begin accessing support. Ensure to follow the outlined steps for proper submission.
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How do I fill this out?
Filling out the OCREVUS Start Form is a straightforward process. Begin by reading all instructions to understand each section's requirements. Complete the necessary sections, ensuring all required fields are filled accurately before submission.
How to fill out the OCREVUS Start Form - Patient Enrollment Instructions?
1
Read the Patient Authorization Information on Pages 2 and 3.
2
Fill in SECTION 1 and sign and date SECTION 1A on Page 4.
3
Sign and date SECTION 1B if enrolling in additional programs.
4
Complete SECTION 1C if eligible for GATCF.
5
Your health care provider should fill out Page 5 and return the form.
Who needs the OCREVUS Start Form - Patient Enrollment Instructions?
1
Patients seeking financial assistance for OCREVUS treatment.
2
Health care providers assisting patients with enrollment.
3
Individuals interested in Genentech patient support services.
4
Patients needing infusion site identification assistance.
5
Caregivers managing health-related documents for patients.
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What are the instructions for submitting this form?
To submit the OCREVUS Start Form, fax it to (877) 312-2193 or send it through your healthcare provider. Ensure that all fields are completed and signatures are included for processing. For further questions about submission, contact OCREVUS Access Solutions at (800) 888-2882.
What are the important dates for this form in 2024 and 2025?
Important dates regarding the OCREVUS Start Form include necessary deadlines for patient enrollment and application submissions, particularly ahead of treatment cycles in 2024 and 2025. Ensure all required paperwork is completed well in advance to avoid treatment delays. Check with your healthcare provider for specific timelines.
What is the purpose of this form?
The primary purpose of the OCREVUS Start Form is to facilitate enrollment in Genentech's patient support services. By filling out this form, patients gain access to essential assistance, including financial resources and medication coordination. It also allows for the collection of vital health information necessary for ongoing support.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Contains personal details about the patient, including name, contact information, and insurance details.
- 2. Diagnosis Code: Requires input of the diagnosis code to validate the need for OCREVUS.
- 3. Authorization Sections: Includes different sections for patient consent, benefits investigation, and additional program enrollments.
- 4. Healthcare Provider Details: Information required from the healthcare provider to process assistance requests.
- 5. Signature Fields: Designated areas for the patient and provider signatures to authorize service requests.
What happens if I fail to submit this form?
Failing to submit the OCREVUS Start Form can impede access to essential patient support services. Without proper authorization, the Genentech services cannot assist in coordinating treatment or financial resources.
- Delayed Access to Medication: Patients may experience delays in obtaining their medication and support due to incomplete forms.
- Ineligibility for Support Services: Failure to submit may result in the patient missing out on potential financial assistance.
- Disruptions in Treatment Plan: Delay in form submission can disrupt the patient's treatment plan and management.
How do I know when to use this form?
- 1. Initial Enrollment in Patient Support: Used for patients initiating the process to access medication support and services.
- 2. Applying for Financial Assistance: When patients seek to determine eligibility for free medication or co-pay assistance.
- 3. Updating Personal or Health Information: To reflect any changes in the patient's health status relevant to their treatment.
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