Nemluvio Patient Enrollment Form – Printable & Fillable PDF
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Nemluvio Enrollment Form |
Patient Support Program |
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Nemluvio Enrollment Form
Starting a Nemluvio treatment often requires multiple steps, including insurance verification and prescription approval. The Nemluvio enrollment form is used to collect patients’ information, insurer details, clinical history, and prescription instructions, helping patients enroll in the Galderma Patient Assistance Program and support services, such as specialty pharmacy coordination, prior authorization, insurance verification, and financial assistance. Download and fill out the form today and initiate treatment and dedicated assistance without unnecessary delays.
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Advantages Of Nemluvio Patient Enrollment Form
Coverage Support
The form requires copies of the patient’s insurance card and benefit information. Additionally, it allows Galderma Patient Services to work with insurers, identify requirements, and reduce delays in Nemluvio treatment.
Enrollment in Galderma Patient Services (GAP)
By submitting the Nemluvio patient enrollment form accurately, the patient automatically enrolls in GPS, which offers insurance appeals guidance, medication education, and ongoing treatment management.
Bridge and Quick Start
It offers temporary supply options while insurance is being processed. Qualified patients can obtain temporary supplies through the Bridge or Quick Start Programs.
Key Sections of The Nemluvio Patient Form PDF
1- Patient Information Section
This section includes the patient’s information, such as their full name, address, date of birth, gender, contact preferences, and guardian details if applicable.
2- Provider Information
It provides details about physicians, including name, practice, NPI number, contact number, and office information.
3- Clinical Information
Contains clinical information, including diagnosis codes, previous treatments, allergies, and disease impact.
4- Prescription Information Section
The section includes dosing instructions, weight, and maintenance schedules.
5- Insurance Details
It contains insurance information, including name, address, group number, member ID, etc.
6- Patient Assistance Program (PAP) Section
This section lets commercially insured eligible patients apply for income-based financial support, including free and reduced-cost medication.
7- Prescriber Attestation Signature
Requires prescriber signature to confirm medical necessity and compliance with state/federal requirements for prescribing Nemluvio.
How To Complete The Nemluvio Enrollment Form?
Insurance Information: Attach the front and back of the insurance card and provide insurance ID, BIN, PCN, and group number. Check the “No Insurance” box if you don’t have insurance.
Choose Preferred Specialty Pharmacy: Select the desired specialty pharmacy from the given checkboxes.
Patient Information: Fill in the patient’s name, date of birth, gender, address, email address, preferred contact time, and phone number. If the patient is under the care of guardians, provide their full name, the relationship between the patient and the guardians, and any other relevant information.
Patient Authorization & Other Consents: The patient or the legal guardian must sign and date the patient authorization section
Patient Assistance Program (Optional): Eligible patients with commercial insurance can request NEMLUVIO when they do not have adequate coverage for the product. It requires additional information, such as the number of people in the household, annual household income, and a patient or legal guardian’s signature, among other details.
Provider Details: Fill in the provider’s information, such as specialization, full name, HCP title, practice name, office contact details, NPI number, and address.
Clinical Information: Select prior treatments, and mention concurrent medication, known drug allergies, or any disease impact. Also, select appropriate diagnosis code.
Patient & Prescriber Information: Provide the patient’s legal name, date of birth, address, phone number, along with the prescriber’s name, address, NPI number, state’s license number, etc.
Prescription Information: Describe the patient’s weight, whether the patient started Nemluvio on a sample, and preferred medication delivery. Select the required dosage quantity, frequency, refills, and GPS for Nemluvio Free Goods Program: Quick Start/Bridge/PAP.
Prescriber Attestation: The prescriber must sign and date the form to certify that the Nemluvio is medically necessary and the provided information is accurate to the best of their knowledge.
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Frequently Asked Questions
What is the Nemluvio enrollment form?
It is the official document used to start Nemluvio treatment and enroll patients in Galderma Patient Services. Additionally, the form gathers required necessary information of the patient, insurer, physician, and prescription instructions.
Who can complete the form?
Both the patient or their legal guardian and the prescribing healthcare provider must complete and sign their respective sections.
Can I submit the form without attaching an insurance card?
A missing document can delay or cause the denial of coverage. Therefore, it is necessary to attach front and back copies of the insurance card.
What services can I avail after enrollment?
By completing and submitting the form, the patients can avail insurance assistance, QuickStart, Bridge programs, copay support, appeal support, and pharmacy coordination.
Is financial assistance available?
of course, the form contains a dedicated section for the Patient Assistance Program, allowing eligible patients to receive free or out-of-pocket medication.
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