RINVOQ Enrollment Form – Dermatology Patient Support PDF
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RINVOQ Enrollment Form |
Prescription Form |
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RINVOQ Complete Enrollment Form
Patients diagnosed with moderate to severe atopic dermatitis (Eczema) may need the proper and structured support to initiate treatment. The Rinvoq enrollment form helps eligible patients connect with AbbVie’s Rinvoq Complete program, which offers prescription coordination, personalized support, insurance assistance, and resources to start treatment. Additionally, this form lets healthcare providers and patients work together, ensuring all required information, such as medical, clinical, and insurance, is submitted correctly to avoid unnecessary delays. Fill out the form now and start your enrollment today to get ongoing guidance.
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Advantages Of RINVOQ Enrollment Form
Nurse Ambassador Support
Once enrolled, the patients get a call from a Rinvoq Complete Nurse Ambassador within one business day. They provide 1-to-1 non-medical support and help with insurance coverage.
Optional e-Prescription Submission
The healthcare provider can directly submit a prescription via email or fax, reducing additional steps and paperwork.
Insurance Approval Assistance
The Rinvoq enrollment form gathers all required insurance details and clinical data to help healthcare providers initiate the benefit verification, financial assistance, and authorization process.
Key Sections of the RINVOQ Dermatology Enrollment Form
1- Patient Information Section
The first section of the RINVOQ enrollment form describes the patient’s details, including their full name, address, gender, date of birth, and other contact details.
2- Insurance Information
This section requires attached copies (front and back) of the patient’s medical and prescription cards, which help verify coverage and are required for enrollment.
3- Diagnosis
In this section, the healthcare provider confirms the patient has moderate to severe atopic dermatitis. It includes the diagnosis name and date of diagnosis.
4- Prescriber Information
It contains prescriber’s details, such as full name, NPI number, office phone and fax number, office address, etc.
5- Clinical Information
The section supports patients’ eligibility, including their current weight, TB test data and result, and past treatments.
6- Pharmacy Prescription (Optional)
This is an optional section that allows the prescriber to write a Rinvoq prescription, including medication strength, quantity, refills, and preferred specialty pharmacy. Additionally, this section also requires the prescriber’s signature and date.
7- Rinvoq Complete Prescription
The Rinvoq Complete prescription section is only required if the patient is commercially insured and is facing unnecessary delays or denial in insurance coverage.
How To Fill Out RINVOQ Patient Enrollment Form?
Start With Patient Details: The patient or authorized guardian should complete this section by providing their name, date of birth, complete address, relationship to the patient, and mobile number.
Write the Insurance Details: Attach the front and back copies of the prescription and medical insurance cards.
Prescriber Information: Specify the prescriber’s name, contact details, full address, NPI, and office details.
Clinical and Diagnosis Information: This section should be filled by the healthcare provider, describing the date of diagnosis, current weight, and prior treatments.
Pharmacy Prescription: Write the Rinvoq dose, quantity, and number of refills.
Rinvoq Complete Prescription: The eligible commercially insured patients can avail of a temporary supply through AbbVie’s support.
Consent: Review and accept the privacy notice, including data handling policies and marketing consents.
Submit: Once completed, email or fax the form.
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Frequently Asked Questions
What is the Rinvoq enrollment form used for?
This is an official document used to enroll eligible patients with moderate to severe atopic dermatitis into AbbVie’s Rinvoq Complete support program. It allows AbbVie to collect all necessary information about the patient, insurance, clinic, and prescriber, enabling support services, including benefit verification, insurance assistance, and non-medical support.
What types of support are provided after enrollment?
After enrollment, the patients can get 1-to-1 non-medical support from a Rinvoq Nurse Ambassador. Also, they can access the Rinvoq Complete App to get medication reminders, log treatment progress, and educational resources.
Can the form be filled out digitally?
Of course, StartForms provides a fillable version of the form, which must be printed and faxed after completion. Electronic submission is not supported or accepted via email.
Can I apply for Rinvoq patient assistance through this form?
This form is the initial step toward accessing Rinvoq Patient Assistance programs. If the patient is delayed or denied, but meets eligibility criteria, they may qualify for a temporary no-cost supply through AbbVie’s authorized pharmacies.
Is the Rinvoq savings card part of this enrollment?
The Rinvoq savings card is a separate option, which is available only for the eligible commercially enrolled patients. The enrolled patients may be encouraged to apply for savings programs that reduce out-of-pocket costs.
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