OFEV Enrollment Form PDF – Apply Online for Financial Assistance
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OFEV Enrollment Form |
Patient Support Program |
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PDF, Fillable PDF |
OFEV Enrollment Form
The HeadStart Patient Assistance Program helps patients to initiate OFEV (nintedanib) treatment by providing support with insurance reimbursement, a temporary bridging supply of medication, and ongoing medical support. While the OFEV enrollment form gathers all necessary information related to the patient and physician, including medical diagnosis, test results, and prescription, ensuring eligibility and proper coordination with insurers and pharmacies. Access, fill out online, or download the fillable form, and submit to access support services without unnecessary delays.
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Advantages Of OFEV Enrollment Form
Quick Access to Bridge Medication
The form lets patients connect with the HeadStart Program to receive a temporary supply of OFEV until insurance or reimbursement is confirmed. Additionally, this confirms there are no treatment gaps.
Comprehensive Patient Assistance Services
Once enrolled in OFEV, patients are supported by a HeadStart Nurse Care Manager who directly coordinates with physicians, insurers, and pharmacies, helping patients manage medication requirements effectively.
Patient & Caregiver Authorization
The OFEV Open Doors enrollment form allows a patient or an authorized caregiver to sign and manage on behalf of patients who may be unable to sign due to health limitations.
Key Sections of The OFEV Prescription Form
1- Patient Section
This section includes the patient’s legal name, complete address, contact details, health card number, and preferred language.
2- Diagnosis & Test Results
It confirms eligibility through clinical data, such as HRCT results, FVC, DLCO, and other pulmonary function values.
3- Consent & Authorization
It requires the patient or caregiver’s signature authorizing the collection, use, and disclosure of personal and medical information.
4- Physician Details
Collects physicians’ information, including their name, medical license number, office contact details, and prescribing authority.
5- Prescription Information
The section specifies dosage quantity, refills, frequency, and supply duration.
6- Adjunct Medication/Bloodwork
This is an optional section for supportive care prescriptions, such as antidiarrhea tablets and blood test requisitions.
How To Complete The OFEV Enrollment Form PDF?
Patient information: Provide the patient’s details, including their complete name, address, date of birth, patient record number, provincial health card number, preferred phone number, and email address. Also, indicate your language preference and communication method.
Medical Diagnosis & Prescription: The prescriber must choose the appropriate condition and attach supporting medical documents, such as an HRCT or a lung function test result. Additionally, fill in the medicine dosage, quantity, number of refills, frequency, and special instructions (if any).
Physician Information: Specify the physician’s name, medical license number, address, including city, province, and postal code, phone & fax numbers, and nurse or office contact details.
Adjunct Medication: This is an optional section where the prescriber can request additional medication for acute diarrhea.
Patient & Physician Authorization: The patient and the physician must sign and date the form to authorize or consent.
Download OFEV Enrollment Form PDF
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Frequently Asked Questions
What is the purpose of the OFEV enrollment form?
The form is used to enroll patients into the HeadStart Patient Assistance Program, which provides access to OFEV and related support services, including reimbursement assistance and temporary bridging medication supply.
Can a caregiver submit the form on behalf of the patient?
If the patient is unable to sign or consent to the form due to their health limitations, an authorized caregiver or legal representative can submit the form. The caregiver’s relationship with the patient must be mentioned on the form.
Do I have to provide the medical test results with the form?
Yes, you have to attach the required medical test results, such as HRCT, FC, and DLCO.
Does the program offer support with side effects?
Of course, the form includes a section for adjunct medication, such as loperamide for diarrhea management, and allows physicians to request bloodwork.
What if I don’t have insurance coverage yet?
The program provides support and bridge medication, even if the insurance coverage is in process.
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