Litfulo Enrollment Form – Printable PDF for Alopecia Areata
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Litfulo Enrollment Form |
Patient Support Program |
06 Pages |
PDF, Fillable PDF |
Litfulo Enrollment Form
Starting treatment with Litfulo requires completing the Litfulo enrollment form. It collects patient, insurance, and prescriber information, allowing patients and healthcare providers to start processing Litfulo through Pfizer Dermatology Patient Access. By submitting it, the patients can benefit from insurance verification, copay assistance, and patient support services. To avoid delays, make sure the form is filled out correctly and submitted on time. You can easily download, fill out, and submit the form to initiate your treatment process.
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Benefits of The Litfulo Patient Form
Easier Access to Patient Support Programs
Patients may qualify for financial assistance, free medication programs, and copay. Completing and submitting the form correctly lets Pfizer review eligibility and connect patients to available support resources.
Optional Access
Patients may choose to work with a Pfizer patient access coordinator who can explain insurance requirements, assist with coverage challenges, and provide support during the process.
Accurate Insurance Verification
The Litfulo enrollment form allows Pfizer Dermatology Patient Access to verify coverage, check prior authorization requirements, and confirm benefits, reducing the risk of treatment delays due to missing insurance-related data.
Key Sections of The Litfulo Enrollment Form
1- Patient Information Section
This section includes the patient’s required details, including their name, address, gender, date of birth, phone number, email, and caregiver’s information.
2- Insurance Details
Includes primary, secondary, and prescription information, including insurance names, addresses, phone & fax numbers, license numbers, BIN, PCN, group & ID numbers, and insurance cards.
3- Prescription Selection
It allows patients or healthcare providers to choose an appropriate prescription, such as Litfulo 50 mg.
4- Privacy Notice, Consent, and Signature
This section covers consent and the required patient’s signature to grant permission to share medical details for support activities.
5- Prescriber Information
Describes prescriber’s name, complete address, office details, phone & fax numbers, NPI, etc.
6- Diagnosis & Prescription Details
Includes ICD-10 codes and specific Litfulo prescription, such as dosage, frequency, refills, etc.
7- Healthcare Provider Certification
The last section of the form requires the prescriber’s signature to certify that the treatment is medically necessary.
How To Complete The Litfulo Enrollment Form?
Patient Prescription Selection: Select one medication, such as Litfulo, from the given check boxes.
Patient Information: Write the patient’s full name, date of birth, gender, complete address, primary phone number, email, best time to contact, and caregiver’s contact details.
Insurance Information: Select the insurance type and fill in the policyholder name, insurance name, insurance phone number, policy ID, group number, PCN, and BIN of the primary & prescription insurance.
Patient Consent & Signature: The patient or their representative must print their name along with their signature and date.
Prescriber Information: Write the prescriber’s name, state license number, NPI, complete address, office contact details, and email.
Diagnosis: Select the appropriate ICD-10 codes for Litfulo.
Prescription Information: Indicate the allergies (if any) and specify dosage frequency, refills, and concomitant medications.
Healthcare Provider Certification: The healthcare provider must print their name along with their signature and date.
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Frequently Asked Questions
What is the Litfulo enrollment form?
The form is used to collect necessary information from the patient, the prescriber, and the insurance. Pfizer Dermatology Patient Access can verify insurance coverage, provide access to Litfulo treatment, patient support services, and financial programs.
Can minors use this form?
Of course, if the patient is under 18, the caregiver must provide their name and contact details. Also, the caregiver must sign the authorization section.
How does the form support financial assistance?
By completing, signing, and submitting the form, patients can be eligible for copay assistance or free medication programs.
How is the form submitted?
The prescriber can submit the form via fax or the Pfizer Dermatology HCP Portal. They can also e-prescribe to Sonexus Health Pharmacy Services.
How long is the authorization valid?
The authorization may be valid for 4 years unless the patient withdraws it earlier in writing.
Related Forms
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