ZEPOSIA Enrollment Form and Patient Instructions
This file provides essential guidelines and details for obtaining ZEPOSIA (ozanimod). It includes patient information, insurance coverage, and authorization requirements. Follow the instructions carefully to ensure successful enrollment in ZEPOSIA 360 Support.
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How do I fill this out?
To fill out this form, begin by gathering required patient information, including personal and prescription insurance details. Ensure all sections are completed accurately to avoid delays in processing. Finally, review and sign the Patient Authorization and Agreement.
How to fill out the ZEPOSIA Enrollment Form and Patient Instructions?
1
Gather necessary patient information and insurance details.
2
Complete all relevant sections of the form.
3
Read and understand the Patient Authorization and Agreement.
4
Sign the form to authorize processing.
5
Submit the form through fax or online as instructed.
Who needs the ZEPOSIA Enrollment Form and Patient Instructions?
1
Individuals prescribed ZEPOSIA who need assistance with enrollment.
2
Healthcare providers needing to submit patient information for treatment.
3
Insurance agents assisting patients in understanding coverage options.
4
Patients seeking financial support programs related to ZEPOSIA.
5
Caregivers or legal representatives handling enrollment for others.
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What are the instructions for submitting this form?
To submit this completed form, you may fax it to 1-833-727-7701 or use the online submission platform available through ZEPOSIA 360 Support. Alternatively, you can mail it to Bristol-Myers Squibb, PO Box 310, Columbus, OH 43216. Ensure that all necessary signatures and documentation are included to prevent any delays in processing.
What are the important dates for this form in 2024 and 2025?
Patients should be aware of any specific deadlines related to enrollment and medication refills for the ZEPOSIA program in 2024 and 2025. It's important to review the terms and conditions in the form and ensure all applications are submitted within stipulated time frames to avoid missed opportunities for support. Marking these dates on your calendar will help in staying organized and informed.
What is the purpose of this form?
The primary purpose of this form is to facilitate the enrollment of patients into the ZEPOSIA 360 Support program. This includes providing essential information on treatments available, financial assistance options, and necessary healthcare guidance. By completing this form, patients and healthcare providers can streamline the process of obtaining ZEPOSIA and ensure they receive all available benefits.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Details including name, date of birth, sex, address, and contact information.
- 2. Prescription Insurance Coverage: Information regarding insurance carriers and member identification numbers.
- 3. Baseline Assessments: Option for healthcare providers to indicate assessments required for therapy initiation.
- 4. Diagnosis & Prescription(s): Fields for documenting primary diagnosis and treatment plans.
- 5. Prescriber Information: Information about the healthcare provider prescribing ZEPOSIA.
- 6. Prescriber Authorization: Certification by the prescriber regarding the validity of the prescriptions.
What happens if I fail to submit this form?
Failure to submit this form correctly may result in delays in obtaining medication or support services. Without proper completion, applications for financial assistance may not be processed, leading to potential out-of-pocket costs for patients.
- Incomplete Information: Missing details may hinder the patient's ability to enroll in support programs.
- Delayed Processing: Failing to provide signatures or required documentation can delay pharmacy fulfillment.
- Loss of Benefits: Patients may miss out on reimbursement or financial aid opportunities.
How do I know when to use this form?
- 1. Patient Enrollment: To register patients in the ZEPOSIA support program.
- 2. Insurance Verification: To verify and document insurance coverage for ZEPOSIA.
- 3. Assistance Application: To apply for financial aid or medication assistance.
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How do I ensure my edits are saved correctly?
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Is free medication available through this form?
Eligible patients can access free medication options outlined in the enrollment instructions.
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