Cibinqo Enrollment Form – Download Patient Access PDF
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Cibinqo Enrollment Form |
Patient Support Program |
05 Pages |
PDF, Fillable PDF |
Cibinqo Enrollment Form
Starting treatment with Cibinqo (Abrocitinib) requires more than simply writing a prescription. The patients often need assistance with insurance coverage, financial support, and pharmacy coordination. The Cibinqo enrollment form simplifies this process by gathering all the necessary insurance, medical, and consent information in one document. Completing this form helps avoid delays, ensures accurate benefits verification, and provides faster access to financial assistance programs and support services. Download, complete, and submit the form today to start treatment without unnecessary interruptions.
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Benefits of The Cibinqo Patient Enrollment Form
Insurance Benefits Review
By submitting the form correctly, the patient authorizes Pfizer Dermatology Patient Access to arrange a comprehensive benefits investigation, including checking insurance coverage, identifying prior authorization requirements, and appeal assistance if coverage is denied.
Interim Car Coverage
If insurance is delayed, the Interim Care program offers a short-term supply of Cibinqo at no cost to eligible patients with commercial insurance.
Eligibility For Patient Assistance Programs
Eligible patients who are commercially insured and qualify can access copay support programs or receive free medication through Pfizer Dermatology Patient Access. This reduces financial stress, making treatment more affordable.
Key Sections of The Cibinqo Enrollment Form PDF
1- Patient Section
It includes the patient’s details, including their name, address, contact numbers, preferred language, and caregiver information.
2- Prescription Insurance Information
This section describes various types of insurance coverage, including commercial, Medicare, Medicaid, and other forms, along with policyholder information.
3- Patient Consent to Communication
It authorizes Pfizer to provide status updates, refill reminders, and financial support notifications.
4- Healthcare Provider Section
The section contains healthcare provider details, such as name, specialty, license number, NPI, and contact numbers.
5- Clinical Information
Includes ICD-10 diagnosis codes.
6- Prescription Information
It specifies Cibinqo dosage, frequency, refills, etc.
7- HIPAA Consent
The healthcare provider HIPAA consent section confirms the prescriber’s authorization to share patient details and validates the medical necessity of treatment.
8- Patient Authorization
This section allows permission for healthcare providers and insurers to share information with Pfizer to support benefits verification, prior insurance, and assistance programs.
How To Complete The Cibinqo Enrollment Form?
Patient Information: Write the patient’s first, middle, and last name, date of birth, gender, address, including city, state, and ZIP code, primary phone number, language preference, email address, and caregiver details.
Prescription Insurance Information: Select the coverage type, such as commercial, Medicare, Medicaid, or other. Also, provide insurance details, including primary insurance name, primary insurance phone number, policyholder name, prescription insurance details, etc.
Patient Consent: The patient must sign the form to agree to communications from Pfizer, Pfizer Dermatology Patient Access, or parties acting on their behalf to determine the patient’s eligibility.
Healthcare Provider Information: Fill in the prescriber’s name, specialty, state license number, practice name, full address, NPI number, fax number, and office contact details.
Clinical Information: Provide the primary diagnosis code (ICD-10).
Prescription: Write the prescribed Cibinqo medication details (abrocitinib or crisaborole), including frequency, quantity, and refills.
Healthcare Provider HIPAA Consent & Attestation: The prescriber must sign and date the form to certify that the provided information is accurate and the treatment is necessary.
Patient Authorization: Print the name of the patient along with their signature, and the patient representative’s name.
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Frequently Asked Questions
What is the Cibinqo enrollment form?
The form is designed to collect all necessary patient, insurance, and prescription information, helping Pfizer Dermatology Patient Access verify benefits, support prior authorizations, provide financial assistance options, and coordinate pharmacy services for Cibinqo or Eucrisa.
Can the form be used for other medications?
Yes, rather than Cibinqo (abrocitinib), the form allows prescriptions for Eucrisa (crisaborole) ointment.
What financial assistance options are available through the form?
By completing and submitting the form, the patient may be eligible for copay support programs and free medication programs. It reduces the out-of-pocket cost of treatment.
Are Medicare or Medicaid patients eligible for Interim Care Rx?
No, the Interim Care program is only for eligible, commercially insured patients. Therefore, patients with Medicaid, Medicare, or government health programs are not eligible.
Is signing the form mandatory for treatment?
No, the patients can still receive treatment, but without the form, they may not be able to access benefits investigation, copay assistance, or other patient support services.
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