Cabenuva Enrollment Form – Fillable PDF for Patient Assistance
|
Form Name: |
Category: |
Page Count: |
File Format: |
|---|---|---|---|
|
Cabenuva Enrollment Form |
Patient Support Program |
05 Pages |
PDF, Fillable PDF |
Cabenuva Enrollment Form
The Cabenuva enrollment form is an important document used by healthcare providers and patients to enroll in the ViiVConnect Support Program. It helps patients to start or continue Cabenuva treatment with access to benefit verification, copay support, and patient assistance programs. Submitting this form ensures accurate prescription processing and faster access to medication. To get started, download and complete the form today to simplify your treatment process.
Form Preview
Benefits of The Cabenuva Start Form
Copay and Financial Assistance
The form is used to assess eligibility for the Co-Pay Savings Program and the ViiVConnect Healthcare Patient Assistance Program. Patients with private insurance may receive copay support, while uninsured or underinsured patients may qualify for free or discounted medication.
Cabenuva Support Services
The Cabenuva enrollment form brings all support services into one place, including medication enrollment, benefits verification, financial assistance, and prescription coordination.
Accurate Insurance & Benefits Verification
By completing the form, ViiVConnect can contact insurance providers to verify coverage, determine out-of-pocket costs, and inform the patient about available financial support options.
Key Sections of The Cabenuva Enrollment Form
Patient Information Section
This section includes the patient’s name, address, gender, date of birth, phone number, and email address.
Insurance Details
It includes primary & secondary insurance information, including insurance name, BIN, PCN, policy ID, and group number.
Prescriber Information
It includes the prescriber’s name, practice details, NPI number, and contact preferences.
Prescription
This section describes medication type, dosage, frequency, quantity, and refills.
Financial Information
Specifies the household income and funding details for determining eligibility for the Patient Assistance Program.
Pharmacy & Shipping Details
The section describes preferred pharmacy, delivery site, and contact preferences.
How To Complete The Cabenuva Enrollment Form PDF?
Patient Information: Start with the patient’s full name, mailing address, date of birth, gender, phone number, and email.
Patient Authorization: Write the patient’s name, including the signature and date. If the patient has a legal guardian, provide their name, signature, and relationship to the patient.
Insurance Information: Specify whether the policy is commercial, Medicare, or Medicaid. Fill in the policyholder’s name, relationship to patient, medical insurance name, prescription medicine plan name, insurance phone & fax numbers, policy ID, group, etc. Also, attach the front and back copies of the insurance cards.
Injectable Prescription Information: Select the prescription/schedule, ICD-10 codes, medication, quantity, refills, and directions.
Oral Prescription Information (Optional): Choose the oral medication type and indicate where to ship it, such as the prescriber’s office, the patient’s home address, or another location.
Prescriber Details: Write the prescriber’s name, practice name, office details, phone number, fax number, prescriber tax ID, state license number, NPI, and email address.
ViiV Healthcare Patient Assistance Program (PAP): If the patient has limited insurance coverage, this section determines eligibility for free or discounted medication through the Patient Assistance Program.
Injection Acquisition Information: Choose whether the patient should start with oral medication or proceed directly to Long-Acting Injectable kits.
Prescriber Declaration: The prescriber must sign the form, confirming that all the information is accurate.
Download Cabenuva Enrollment Form PDF
Choose your preferred format and download instantly
Frequently Asked Questions
What is the purpose of the Cabenuva enrollment form?
It is used to enroll patients into Cabenuva support services offered through ViiVConnect. These services include benefits verification, prescription processing, copay assistance, PAP, and medication coordination.
Who needs to complete the form?
The patient and the prescriber must complete and sign their respective sections. The patient fills in the personal details and insurance information, then signs the authorization. The healthcare provider completes their personal details, prescription instructions, and signs the prescriber declaration.
Does the form help verify my insurance coverage?
Of course, the insurance section allows ViiVConnect to contact your insurance provider to confirm coverage, check eligibility for financial support, and determine expected out-of-pocket costs.
Where can I submit the completed form?
You can either upload it directly through the ViiVConnect Provider Portal or fax it to the official ViiVConnect fax number mentioned on the form.
What documents are required along with the form?
Typically, front and back copies of the insurance cards, proof of income, and prescriber information are required.
Related Forms
Apply for patient support and access to Xolair treatment for asthma and chronic hives.
Used to enroll patients prescribed Litfulo (ritlecitinib) for access to treatment, insurance coverage assistance, and participation in the Pfizer patient support program.