Ingrezza Start Form – Tardive Dyskinesia Patient Enrollment PDF
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Ingrezza Start Form |
Patient Support Program |
02 Pages |
PDF, Fillable PDF |
Ingrezza Start Form
The Ingrezza start form is a standardized document used to initiate enrollment into the Ingrezza (Valbenazine) Start Program, which helps eligible patients gain access to free trial supply, reimbursement assistance, and ongoing support services. Start your enrollment today by downloading and filling out the form to ensure timely access to care and program resources.
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Advantages Of Ingrezza Start Form
Insurance & Reimbursement Support
By authorizing the program, the eligible patients may receive help with insurance coordination and reimbursement, minimizing financial cost and administrative burdens.
Patient Assistance Options
The eligible patient, who meets the program criteria, can receive a one-time, one-month free trial at no cost, ensuring treatment starts without any financial burden.
Copay Card & Financial Support Guidance
The form authorizes the program to connect patients with financial assistance programs, including copay card and other options if applicable.
Key Sections of The INGREZZA Patient Assistance Form
1- Patient Section
This section contains the patient’s information, including name, address, contact details, residence type, etc.
2- Prescriber Section
It must be filled out by the prescriber, including their name, NPI, complete address, phone number, and prescribing details.
3- LTC/NFS/Assisted Living Section
Fill in long-term care or skilled nursing facilities.
4- Clinical Data
It describes diagnosis information, allergies, or other relevant conditions.
5- Start Program Prescription
This section lets the prescriber choose one of the provided dosing options and free trial enrollment.
6- Signature
It requires the prescriber’s signature and date of application to certify authorization to forward the prescription.
How To Complete The Ingrezza Start Form?
Patient Information: Enter the patient’s full name, last four (4) digits of SSN, date of birth, address, city, state, ZIP code, email address, preferred phone number, patient residence, etc.
Prescriber Information: The healthcare provider must fill it out, including name, NPI, facility name, address, phone number, office contact details, and prescribing information.
Facility Details: Specify the resident’s room number, facility pharmacy name, facility pharmacy address, and choose the prescription shipping.
Clinical information: Choose the diagnosis, such as tardive dyskinesia or Huntington’s chorea. Also, specify any allergies and other diagnosis.
Ingrezza Start Program: It allows prescribers to select dosing options or indicate an alternative prescription with specific instructions.
Prescriber Certification: The prescriber must sign and date the form to certify medical necessity and compliance with program terms.
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Frequently Asked Questions
What documents are required to submit with the form?
In some states, it is necessary to attach the official state prescription form.
Can residents in Medicare Part A facilities apply?
The patients currently covered under Medicare Part A facility are not eligible for the free trial program.
Can a caregiver contact be included?
Of course, the form lets patients provide details of an authorized representative or alternative contact to assist with communication and coordination with the support program.
Who is eligible to use this form?
The Ingrezza Program is available for adults who are diagnosed with tardive dyskinesia or Huntington’s chorea. However, patients who are covered under Medicare or Medicaid are not eligible for a free trial supply program.
What is the Ingrezza start form?
The form is used to enroll eligible patients into the Ingrezza Start Program, which provides a free trial supply of Ingrezza, patient assistance options, reimbursement support, and access to treatment-related services.