Humira Enrollment Form – Printable PDF for Fast Submission
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Humira Enrollment Form |
Specialty Medication Enrollment |
04 Pages |
PDF, Fillable PDF |
Humira Complete Enrollment Form
Starting treatment with Humira requires more than receiving a prescription. It requires proper documentation, insurance coordination, and patient support to access personalized support services. The Humira enrollment form initiates access to Humira Complete, AbbVie’s patient support programs, including benefits verification, financial assistance, prior authorization assistance, injection training, Nurse Ambassador support, and prescription coordination. Additionally, this form must be completed by the healthcare provider and the patient before starting treatment. Complete it online or download it today to ensure faster access to Humira support and resources.
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Advantages Of Humira Enrollment Form PDF
Direct Access
Completing and submitting the Humira enrollment form allows patients to enroll in the Humira Complete program, delivering full support from start to finish.
Enrollments in Savings and Assistance
Humira patient enrollment form activates access to multiple financial support options, including a copay saving card, a bridge to therapy program, a patient assistance program, and a government insurance program.
Insurance Navigation Assistance
One of the main advantages of completing this start form is the immediate connection to an Insurance Specialist through the Humnira Complete program. Once the form is signed and submitted, AbbVie assign a dedicated specialist who helps both the patient and the healthcare provider.
Key Sections of the Humira Complete Enrollment Form
1- One-to-One Support
Fill out the 1-to-1 support section to get support from a Humira Nurse Ambassador. The assigned person will contact you after a few days of enrollment, or you can also contact them sooner.
2- Getting Your Prescription
Write your specialty pharmacy name, contact details, and date of your first injection.
3- Preparing To Inject At Home
This section ensures you’re trained enough or authorized to do so by your doctor. Watch self-injection training videos before injecting Humira or ask your Ambassador any additional questions about injection.
4- Patient Information
This section describes the patient’s details, including their name, full address, gender, date of birth and contact details.
5- Insurance Section
It contains the insurance details, including insurance type, cardholder name, medical insurance provider, group number, member ID, prescription insurance, ID, BIN, and PCN numbers.
6- Diagnosis Section
It describes conditions being treated with Humira, including ICD-10 code and date of diagnosis.
7- Prescriber Information
Specifies the prescriber information, such as full name, National Provider Identifier (NPI) number, and options to receive a Prior Authorization Form.
8- Clinical Information
The prescriber describes the previous clinical background, including a list of prior therapies, any allergies, BSA% %, TB test date and results, and additional clinical notes.
9- Injection Training Section
This is an optional section where the prescriber may check the box if the patient needs supplemental injection training.
10- Pharmacy Prescription
Choose the presentation, such as a syringe or a pen, therapy type, indicate SIG, quantity, or refills.
11- Patient Authorization and Consent
This section must be reviewed and signed by the patient to consent to the use of personal, medical, and insurance information and to receive communication through text messages, calls, and emails.
How To Fill Out Humira Ambassador Enrollment Form?
Patient Details: The legally authorized representative or the patient must fill in this section. It includes first and last name, date of birth, gender, full address, email address.
Insurance Details: Write down the insurance details, such as insurer, beneficiary name, medical insurance provider, group number, member ID, etc.
Diagnosis Information: The diagnosis section must be filled by the healthcare provider, choosing the appropriate condition being treated with Humira, such as Ps (Plaque Psoriasis), PsA (Psoriatic Arthritis), and HS (Hidradenitis Suppurativa).
Prescriber Information: Provide the healthcare information, including the prescriber’s full name, full address, state license number, office name, NPI, etc.
Clinical Information: The prescriber must describe the clinical details, including allergies, prior therapies, test date and results, concomitant medications, and additional notes.
Pharmacy Prescription: Choose the accurate Humira formulation and dosage based on the patient’s condition, such as HS, Ps, or PsA.
Signature: The physician, prescriber, and patient signatures are required to certify that the provided information is accurate and that Humira Complete treatment is necessary.
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Frequently Asked Questions
What is the Humira complete enrollment form used for?
Humira patient enrollment form is used to enroll eligible patients in Humira Complete, AbbVie’s official support programs, including benefits verification, copay assistance, and a 1-to-1 nurse.
Can I receive help with the cost of Humira?
Of course, by enrolling, you may become eligible for financial support, including copay savings, bridge programs, or patient assistance. The financial support depends on the patient’s insurance status and financial situation.
What is a Nurse Ambassador?
A Nurse Ambassador is a well-trained AbbVie representative who provides non-medical support to the patients and connects them with specialists.
Is my personal and medical information safe?
AbbVie handles all information in compliance with HIPAA and privacy regulations, making it safer. Once you sign the form, you agree to share your information for enrollment, communication, and coordination of support services.
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