Orenitram 90-Day Trial Program Enrollment Form
The Orenitram 90-Day Trial Program Enrollment Form is designed for new patients to initiate the trial of Orenitram. Patients with a valid prescription can enroll to receive their medication at no cost for 90 days. This program is exclusively available through healthcare providers.
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How do I fill this out?
To fill out the Orenitram 90-Day Trial Program Enrollment Form, start by completing all required patient information. Make sure to provide accurate details, including your prescription information and the healthcare provider's information. Once completed, submit the form to the designated fax number.
How to fill out the Orenitram 90-Day Trial Program Enrollment Form?
1
Complete the patient information section with all required fields.
2
Fill out the prescriber information accurately.
3
Provide prescription details and any additional instructions.
4
Review the form for completeness and accuracy.
5
Fax the completed form to the specified number.
Who needs the Orenitram 90-Day Trial Program Enrollment Form?
1
Patients with pulmonary arterial hypertension who are prescribed Orenitram.
2
Healthcare providers needing to enroll patients in medication trial programs.
3
Pharmacists processing prescriptions for Orenitram.
4
Insurance coordinators reviewing qualification for trial programs.
5
Patient advocates helping individuals with medication access issues.
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What are the instructions for submitting this form?
To submit the Orenitram Enrollment Form, carefully complete all required sections of the document. Fax the completed form to ASSIST at 1-800-380-5294. It is also recommended to confirm receipt of the fax with the designated pharmacy or healthcare provider for effective processing of your enrollment.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates mentioned for the Orenitram Trial Program. However, patients should ensure that they complete their enrollment process promptly to meet eligibility criteria. It is advisable to check with your healthcare provider for any updates regarding the trial program.
What is the purpose of this form?
The purpose of the Orenitram 90-Day Trial Program Enrollment Form is to facilitate access to Orenitram for patients diagnosed with pulmonary arterial hypertension. This program aims to enable new patients to trial the medication without financial burden for 90 days. By providing this opportunity, United Therapeutics Corporation hopes to improve patient outcomes and adherence to prescribed therapies.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Contains fields such as name, date of birth, SSN, and contact information.
- 2. Prescriber Information: Collects details from the prescribing physician, including name, contact info, and NPI number.
- 3. Prescription Information: Includes details about the medication being prescribed, dosage, and administration directions.
- 4. Patient Authorization: A section for patient consent allowing disclosure of personal information.
What happens if I fail to submit this form?
Failing to submit this form may result in delays in accessing Orenitram trial medication. Patients may miss the opportunity to receive the medication for the initial 90-day period. It is crucial to complete and submit the form accurately to ensure eligibility for the program.
- Delay in Medication Access: Incomplete forms can lead to longer processing times, delaying access to needed medication.
- Ineligibility for Trial Program: Mistakes on the form may result in disqualification from the program, preventing patients from accessing their trial medication.
- Waste of Time and Resources: Patients and healthcare providers may need to spend additional time correcting submissions or filling out new forms.
How do I know when to use this form?
- 1. New Patient Enrollment: For new patients prescribed Orenitram to access medications.
- 2. Patient Transitioning to Orenitram: When patients are moving onto a different medication and need Orenitram for treatment.
- 3. Healthcare Provider Referral: At the request of a healthcare provider recommending trial participation.
Frequently Asked Questions
How do I fill out the Orenitram Enrollment Form?
Begin by entering your personal details and prescription information. Ensure all sections are completed before submission.
Where do I submit the form?
The completed form should be faxed to the designated number provided in the document.
Can I edit the PDF on PrintFriendly?
Yes, you can easily edit the PDF using our available tools.
How do I sign the PDF on PrintFriendly?
You can add your signature directly within the document using our signature feature.
Is there a cost associated with this program?
This program is offered at no cost to eligible patients for the duration of 90 days.
Who is eligible for the trial program?
Only new patients with a valid prescription for Orenitram are eligible for the Trial Program.
What should I do if my form is rejected?
Check the details you provided and ensure all required fields are accurately filled, then resubmit.
Can I share my document with others?
Yes, you can share the PDF through email or direct links.
Are there any restrictions on the form?
Yes, only one enrollment per patient is permitted and the offer cannot be combined with other programs.
How can I contact support if I need help?
For assistance, please contact the support team at United Therapeutics through the provided contact details.
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