Taltz Together Enrollment Form Instructions
This file provides essential instructions and enrollment details for Taltz, a dermatological medication. Users will find necessary information regarding insurance and assistance programs. Follow the guidelines for successful completion of the enrollment form.
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How do I fill this out?
To fill out this form, begin by gathering your personal and insurance information. Ensure all required sections are completed accurately before submission. Finally, review the form to confirm all details are correct.
How to fill out the Taltz Together Enrollment Form Instructions?
1
Gather personal information such as name and address.
2
Fill out insurance information correctly.
3
Choose services you wish to enroll in.
4
Sign the form for authorization.
5
Submit the completed form as directed.
Who needs the Taltz Together Enrollment Form Instructions?
1
Individuals who have been prescribed Taltz for dermatological conditions.
2
Patients seeking financial assistance through the Taltz Savings Card Program.
3
Residents of the U.S. or Puerto Rico looking for medication support.
4
Patients without insurance coverage who need to submit proof for assistance.
5
People who want to enroll in services related to Taltz treatment.
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1
Open the PDF document on PrintFriendly.
2
Click on the text fields you wish to edit.
3
Make necessary changes to your personal information.
4
Once edits are made, check the document for accuracy.
5
Save your edited PDF before closing the window.
What are the instructions for submitting this form?
To submit the completed form, you have several options. You can fax pages 1-4 to 1-844-344-8108 or upload the document online at https://patientsupportnow.org with the code 8443448108. For further assistance, call 1-844-TALTZ-NOW during business hours.
What are the important dates for this form in 2024 and 2025?
Key dates for submission and program participation include: Card must be first used by 12/31/2024, and the Card expires on 12/31/2026 or 24 months after the first use, whichever comes first.
What is the purpose of this form?
The purpose of this form is to facilitate patient enrollment in the Taltz Together program, providing patients with essential support and resources. By completing the form, patients can access financial assistance options for Taltz and benefit from additional services like injection training and disposals support. This program was designed to ensure a seamless experience for patients as they begin their treatment journey.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Collects personal details such as name, address, and date of birth.
- 2. Insurance Information: Requires details about the patient's insurance coverage and policy.
- 3. Service Selection: Allows the patient to select services they wish to enroll in regarding Taltz.
- 4. HIPAA Authorization: Grants permission to share Protected Health Information with Taltz Together.
What happens if I fail to submit this form?
Failure to submit this form can cause delays in accessing necessary treatment and support services. Patients may miss out on financial assistance options available through Taltz. It is essential to complete and submit the form accurately to avoid interruptions in your treatment plan.
- Delayed Treatment: Without submission, access to Taltz may be impacted, delaying important treatment.
- Loss of Financial Assistance: Missing out on the Taltz Savings Card could result in higher out-of-pocket costs.
- Incomplete Enrollment: Failure to provide accurate information may lead to incomplete enrollment in support programs.
How do I know when to use this form?
- 1. New Patients: Individuals starting their Taltz treatment for the first time.
- 2. Insurance Changes: Patients needing support due to changes in their insurance coverage.
- 3. Financial Aid: Those seeking financial assistance through the Taltz Savings Card.
Frequently Asked Questions
What is the purpose of this form?
The form is designed for patients to enroll in Taltz Together and access necessary support services.
How do I fill out the form?
Start by gathering your personal and insurance information, then complete all required sections.
What should I do if I have questions while filling out the form?
For assistance, you can call 1-844-TALTZ-NOW for help during business hours.
How can I submit this form?
You can submit the form via fax, online upload, or by mail to the specified address.
Is there a cost for using Taltz Together?
No, participating in Taltz Together services is free for enrolled patients.
Who qualifies for the Taltz Savings Card?
Individuals with commercial drug insurance coverage who meet specific eligibility criteria can qualify.
Can I edit this form after submitting?
Once submitted, you cannot edit this form, but you can request changes through customer service.
What if my insurance denies my coverage?
If coverage is denied, you will be guided on how to appeal and remain eligible for assistance.
How long does the HIPAA authorization last?
The authorization lasts for three years unless you are a resident of Maryland, Maine, or Montana.
What should I do if I change my mind about sharing my PHI?
You can revoke your authorization by contacting Lilly at the provided address.
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