Taltz Enrollment Form – Download Patient Support Program PDF
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Taltz Enrollment Form |
Patient Support Program |
06 Pages |
PDF, Fillable PDF |
Taltz Enrollment Form
The Taltz enrollment form is an essential document required for patients starting treatment with Taltz (ixekizumab) through Lilly Support Service. Additionally, this form collects information related to the patient, prescriber, and insurer to ensure smooth access to assistance programs, including cost-saving options, injection training, medication, and sharps disposal services. To initiate treatment without unnecessary delays, fill out the form correctly, attach any required documents, and submit it.
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Advantages Of Taltz Together Enrollment Form
Free Sharps Disposal Program
The patients who choose sharps disposal will receive a complimentary sharps disposal container, making it safe to discard used auto-injectors or prefilled syringes.
Professional Injection Training
The Taltz enrollment form allows patients to request step-by-step training from a registered and experienced nurse on the correct technique for self-injecting Taltz.
Taltz Saving & Copay Card Eligibility
The eligible commercially insured patients can reduce their treatment cost, just paying as little as $5 for a month’s supply, subject to program limits and terms.
Key Sections of The Taltz Patient Enrollment Form PDF
1- Patient Information
The first section of the form collects the patient’s full name, address, city, ZIP code, state, gender, date of birth, phone number, and contact method. Patients may also consent to receive marketing communications or provide feedback about their treatment.
2- Insurance Section
Here, the patient must describe their primary insurance, including their company name, phone number, cardholder name, policy ID, group number, PCN, etc.
3- Service Selection
The patients have to choose one or more support services, such as a saving card, sharps disposal, and injection training.
4- Prescriber Information Sections
This section collects prescriber details and must be completed by the healthcare provider. It includes the prescriber’s name, full address, practice name, group tax ID, office contact name, etc.
5- Diagnosis
The prescriber must select the applicable ICD-10 code for the patient’s condition.
6- HCP Service Selection & Prescription
This section specifies the device type, dosage, quantity, day supply, refills, and prior treatment history. Also, it allows select either a Lilly-conducted
7- HIPAA Authorization
The patient must sign and date this section to authorize Lilly to access their health information.
How To Complete the Taltz Enrollment Form?
Patient Information: Provide the patient’s full name, address, date of birth, gender, email address, phone number, preferred contact (call, text, or email), and preferred language.
Insurance Information: Write down the primary insurance company name, insurance phone number, cardholder name, policy/ID number, group number, BIN, and PCN.
Service Selection: Check the required service you would like to enroll in by checking the corresponding checkboxes, such as saving card, sharps disposal, or injection training.
Prescriber Information: Describe the prescriber name, NPI number, practice name, office contact details, office address, and collaborating physician name.
Diagnosis: Provide diagnosis, including ICD-10 code for Plaque Psoriasis, Psoriatic Arthritis, or other approved indications.
HCP Service Selection: Choose any required benefit investigation support, such as Lilly conducted benefits investigations or specialty pharmacy conducted benefits investigations.
Taltz Dermatology Prescription: Choose device type, diagnosis, dosing, allergies, contraindications, and prior treatment failures (if any).
Sign and Date: Provide the printed patient name, the patient’s signature, the signature date, and the patient’s date of birth.
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Frequently Asked Questions
What is the Taltz enrollment form used for?
The form gathers all necessary information related to the patient, insurer, and prescriber. It is used to enroll the patient in Lilly Support Services, including savings card, injection training, and benefits investigation.
What documents should I attach to this form?
You need to attach copies of the front and back of your insurance card unless you have no insurance coverage.
Can I apply for a savings card through this form?
Of course, you can request a savings card, which is included within the service selection section of the form.
What services can I request through this form?
You can request enrollment in the Taltz savings card, the sharps disposal container, injection training, and insurance benefits investigation.
What are the eligibility criteria for the Taltz Savings Card?
The patient must be a U.S. or Puerto Rico resident, 18 years or older, have commercial prescription insurance, and not be enrolled in any government-funded healthcare schemes.
What if I don’t have any insurance?
You can still complete and submit the form by choosing the “No Insurance Coverage” option in the insurance section.
Related Forms
Humira Ambassador Enrollment Form
Completing and submitting the Humira enrollment form allows patients to enroll in the Humira Complete program.
The patients may get dedicated nurse Ambassador support for guidance and non-medical support, including treatment education.