Gattex Start Form PDF Download – Fillable Form for Patients
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Gattex Start Form |
Patient Support Program |
02 Pages |
PDF, Fillable PDF |
Gattex Start Form
Patients diagnosed with Short Bowel Syndrome (SBS) often depend on long-term parenteral nutrition and specialized medical care. To begin treatment with Gattex and access support services, the prescribing physician must submit the official enrollment documentation issued by Takeda Pharmaceutical U.S.A., Inc. The Gattex start form is used to document medical necessity, calculate the correct dose, verify insurance coverage, and enroll the patient in Takeda Patient Support Services. If you need a fillable and downloadable version, complete it online today and submit it correctly to avoid unnecessary delays.
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Benefits of the Gattex Patient Enrollment Form
Insurance Verification Support
The form requires copies of medical and prescription insurance cards, allowing Takeda Patient Support to verify benefits, check coverage, and assist with prior authorization.
Access to Financial Assistance Programs
By enrolling through this form, patients may gain access to: Co-pay support, Patient assistance programs, Alternate funding resources. This can significantly reduce out-of-pocket costs.
Enrollment in Takeda Patient Support
Patients are automatically enrolled in Takeda Patient Support once signatures are completed. This includes: Insurance benefit, investigation, Coverage support, Educational resources, Refill reminders (optional text messaging)
Key Sections of the Gattex Start Form
Patient Details
The first section of the form includes full name, DOB, gender, contact details, caregiver information, special precautions, and optional care team members.
Insurance Information
This section requires primary and secondary insurance details, policy ID numbers, group numbers, pharmacy plan information, and copies of both sides of insurance cards.
Prescribing Physician Details
It includes prescribing physician information, including their name, treatment center, address, contact details, NPI, and office contact details.
Patient Clinical Information
The section documents new start or renewal, SBS diagnosis, patient nutrition dependence, and ICD-10 code.
Prescription for Gattex
Specifies calculated dose, volume in ML, kit selection, and refill quantity.
How to Complete the Gattex Start Form Fillable PDF?
Patient Information: Fill in the patient’s full name, date of birth, gender, complete address, phone number, and caregiver details. Also, list any known allergies or precautions.
Insurance Information: Include copies of both sides of the patient’s medical and prescription insurance card(s). Write the primary information, insurance phone number, policy ID, policyholder name, and pharmacy insurance details. Indicate whether the patient does not have insurance.
Prescriber Information: Provide the prescribing physician details, including their full name, treatment center, address, phone & fax numbers, national provider ID, and office contact details.
Patient Clinical Information: Confirm SBS diagnosis, provide appropriate ICD-10 diagnosis codes, and indicate whether this is a new start or renewal.
Prescription for Gattex: Calculate and enter the patient’s dosage.
Authorization for Takeda Patient Support: The prescriber must sign and date the form to confirm the medical necessity.
Patient HIPAA Authorization: The patient or their legal representative must sign the HIPAA authorization and enrollment section.
Submit: Fax the completed form to the number listed on the form or follow office submission procedures.
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Frequently Asked Questions
What is the Gattex start form used for?
It is required to prescribe Gattex (teduglutide) and enroll the patient in Takeda Patient Support. It gathers medical, prescription, and insurance information needed to verify coverage, confirm medical necessity, calculate dosage, and coordinate shipment through the appropriate pharmacy.
Who is responsible for completing the form?
The prescribing physician completes the clinical and prescription sections. The patient or their legal representative must complete and sign the authorization and enrollment sections.
Are both the patient’s and the prescriber’s signatures required?
Yes. The form clearly states that both signatures are mandatory to authorize enrollment and the prescription process.
Can the form be used for renewals?
Of course, there is a dedicated section to indicate whether the patient is a new start or an existing patient renewing Gattex therapy.
Can patients receive financial assistance through this form?
Enrollment through the start form allows patients to be evaluated for co-pay assistance, patient assistance programs, and alternate funding resources. Eligibility depends on insurance coverage and financial criteria.