BRIUMVI Start Form PDF – Enroll in Blituximab-xiiy Support Program
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BRIUMVI Start Form |
BRIUMVI Patient Support |
03 Pages |
PDF, Fillable PDF |
BRIUMVI Start Form
The Briumvi start form is used to initiate the enrollment process for Briumvi treatment (ublituximab-xiiy) and support services. The form gathers all necessary and important information of the patient and healthcare provider, including patient details, insurance details, prescription instructions, infusion site coordination, and authorization for assistance programs. Submitting an accurate and filled form allows Briumvi Patient Support to verify coverage, coordinate benefits, and assist eligible patients in accessing the copay. Download the fillable form for manual submission or start completing it online to initiate the patient enrollment.
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Advantages Of BRIUMVI Start Form PDF
Access to BRIUMVI Copay Assistance Program
The eligible patients with commercial insurance can opt into the BRIUMVI Assistance Program. By checking the appropriate box, patients may get cost-sharing support with out-of-pocket expenses.
Faster Treatment Processing
By providing all required information and signatures accurately, the document reduces delays occured by incomplete submissions, allowing TG Therapeutics to start processing support services immediately.
MS One to One Support Access
Eligible patients can access dedicated one-to-one support, connecting them with program representatives who assist them through coverage processes, scheduling, and ongoing treatment needs.
Free Product Support
Both underinsured and uninsured patients can apply for free product support through the BRIUMVI Patient Assistance Program. The income verification and household size authorization are required to determine eligibility.
Scheduled Dosing and Infusion
The prescription section allows prescribers to specify the dosage for the first, second, and ongoing infusions of BRIUMVI, thereby avoiding errors, ensuring timely ordering, and facilitating coordination with infusion centres.
BRIUMVI Quick Start Program
If the insurance approval is delayed or pending, the eligible patients may be able to recvieve free initial dose thorugh the Quick Start Program, ensuring timely access to treatment while benefit verification is in progress.
Key Sections of the BRIUMVI Patient Support Form
1- Patient Information
This section collects all important details about the patient, including first name, last name, date of birth, gender, address, city, state, ZIP code, email address, preferred language, permanent U.S. resident status, and phone number.
2- Patient Insurance
It contains insurance coverage information for verification, including primary insurance details, the name of the insurance provider, the policyholder’s name, the policy ID, the group number, the insurance phone number, and secondary insurance information (if applicable).
3- Prescriber Information
The healthcare provider must fill out the section. It collects details, such as account name, prescriber first and last name, NPI, state license number, suite number, complete address, and tax ID etc.
4- Clinical and Prescription Information
This area contains diagnosis and prescription instructions, including the ICD-10 code G35 (MS), recently prescribed DMT, allergies, infusion details, and refill information.
5- Infusion Site & Treatment Administration
This section describes how you intend to procure and administer BRIUMVI, such as in-office treatment, site name, address, NPI, tax ID, specialty pharmacy, product procurement method, and infusion options.
6- Signature
The prescriber and the patient have to sign the form with the effective date to authorize that the provided information and prescription are accurate.
How To Fill Out BRIUMVI Copay Assistance Program Form?
Access the Form: Download or access the BRIUMVI star form.
Provide Patient Information: Fill out the patient and insurance details, including the full name, address, phone number, email, date of birth, insurance policy ID, group number, and primary insurance phone number. Additionally, please attach a copy of both the front and back of the insurance cards.
Prescriber Details: Write down the prescriber’s information, including the provider’s name, NPI number, clinic address, and office fax and phone numbers.
Clinical & Prescription Details: Enter the patient’s diagnosis, prior treatment related to BRIUMVI, infusion frequency, dose, and duration.
Authorization and Consent: The patient must sign the form to authorize the use of their information for insurance verification, quick start programs, MS one to one copay assistance programs, and other support services.
Submit: Once completed, fax or email the BRIUMVI star form to the provided number or email address.
Download BRIUMVI Start Form
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Frequently Asked Questions
Can a care partner be involved in the communication?
The form lets patients name the authorize Care Partner, including their contact details and relationship with the patient.
Is there a Quick Start Program available?
As the BRIUMVI form does not mention “Quick Start” by name, but still, eligible patients can avail a short-term free product through the “Patient Assistance Program” while insurance approval is pending or delayed.
Can I use this form to request financial assistance?
BRIUMVI enrollment form includes an option to enroll in the BRIUMVI Copay Assistance Program for eligible patients. Also, this form is used to apply for free products through the Patient Assistance Program (PAP) for both underinsured and uninsured patients.
What is the BRIUMVI start form used for?
It is used to begin treatment with BRIUMVI and the patient enrollment process in TG Therapeutics’ support services, including benefits verification and copay assistance programs. This form contains patient, insurance, prescriber, clinical and prescription information.
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