Gilenya Start Form – Download Fingolimod Prescription PDF
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Gilenya Start Form |
MS Treatment Forms |
2 Pages |
PDF, Fillable PDF |
Gilenya Start Form
The Gilenya start form is a standardized and important document for the patients initiating treatment with Gilenya (fingolimod), a prescription medication for multiple sclerosis (MS). It collects all necessary medical and insurance information, verifies benefit verification, and enrolls you in the Gilenya support program to ensure quick access to treatment. Download or complete your application online with StartForms and avoid unnecessary delays.
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Advantages Of Gilenya Go Program Form
Standardized Information
The Gilenya start form collects all necessary information related to the patient and insurance in one place, allowing insurers to process the application and enrollment faster.
Scheduled First-Dose Observation
The form helps in scheduling first-dose observation at a medical facility, home, or other authorized site.
Free Starter Product
Eligible patients can receive an optional free starter supply of Gilenya (dispensed directly from the Gilenya Go Program). The form allows prescribers to request and specify the shipping address, quantity, and dosage of the starter product.
Complies With HIPAA Regulation
The consent sections ensure that patients’ information is being handled securely and in compliance with privacy laws. Only authorized information will be shared with Novartis and its partners.
Reduces Treatment Delays
The form collects all necessary information, including signatures and documentation, helping avoid processing errors, manual mistakes, missing fields, and delays, ensuring patients can start therapy ASAP.
Simplifies Refills
The Fingolimod start form can be used to simplify refills and ongoing support during the treatment.
Key Sections of the Gilenya Start Form PDF
1- Patient and Insurance Information
The first section of the form collects the patient’s information, including their legal name, date of birth, gender, primary language, caregiver’s information, and personal contact number and address. Additionally, it requires insurance details, such as the insurance name, policy number, group number, prescription ID number, cardholder name, and copies of the insurance cards.
2- Prescriber Information
The healthcare provider completes this section, including their name, address, phone number, state medical license number, NPI number, and email address. It also includes the prescriber’s signature and the effective date, or verify the accuracy of the provided information.
3- Assistance Requested From Gilenya Assessment Network (GAN)
Specify what type of support is being requested from the Gilenya Assessment Network (GAN), such as first-dose observation (FDA), co-pay support, benefit investigation, and macular edema screening.
4- Starter Product Prescription
This is an optional section that allows prescribers to request a free starter supply of Gilenya (dispensed directly from the Gilenya Go Program) and specify its quantity, dosage, and shipping address for the starter product.
5- Ongoing Prescription
It describes the ongoing Gilenya prescription, where the prescriber chooses the supply option, primary diagnosis code, preferred specialty pharmacy, and provides additional notes.
6- Patient Authorization
This is the final section of the form, where the patient consents to share their personal, medical, and insurance details with Novartis and its partners.
How To Fill Out Gilenya Enrollment Form?
Access the Form: Download or open the fillable Gilenya form online.
Enter Patient’s Details: Input the patient information, including legal name, address, date of birth, phone number, etc.
Provide Insurance Details: Enter the insurance name, insurance ID number, prescription insurance name, beneficiary name, and policy numbers. Also, attach clear photos of insurance cards (front and back).
Prescriber Details: This section must be completed by the healthcare provider, including their name, state medical license number, address, phone number, NPI number, and accurate ICD-10 codes.
Select Requested Assistance: Describe the type of support requested from the GAN, including as co-pay support, first-dose observation, benefit investigation, and arranging macular edema screening, ECG, blood tests, or other assessments.
Ongoing & Starter Prescription: Write the ongoing treatment, such as supply options, diagnosis with the ICD-10 code, specialty pharmacy, and additional instructions. Additionally, a prescriber can request a free starter supply from Gilenya.
Consent & Signature: Review and sign the completed application to authorize the use of the patient’s information.
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Frequently Asked Questions
What is the Gilenya start form used for?
Gilenya Start Form is used to gather all necessary information related to the patient, insurance, and prescriber, which is required to initiate Gilenya treatment. It also authorizes enrollment in co-pay or financial support assistance programs, specialty pharmacy, dose scheduling, and benefit verification.
Can I request a free starter supply through the form?
Of course, if eligible, your prescriber can request a free starter product, which is dispensed through the Gilenya Go Program. The prescriber can also specify the dosage, preferred shipping destination, and quantity.
Do I need to sign the form?
Of course, the patient ot their legal guardian can sign the form to authorize sharing of the patient’s personal, insurance, and medical information. The form cannot be processed without a signature.
Do I need to attach additional documents with the form?
Yes. You have to attach both sides of the insurance plan cards, including prescription coverage cards.
How long does it take to process the application?
Process time can be different. Ensure that you provide complete and accurate information to help expedite the process.
Where do I submit the form?
You can either submit the form online or your healthcare provider will fax it to the number listed on the form.
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