Tecfidera Start Form | Download Fillable PDF for Patients
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Tecfidera Start Form |
Patient Support Program |
26 Pages |
PDF, Fillable PDF |
Tecfidera Start Form
The Tecfidera start form is the official document used to initiate Tecfidera treatment for adults with relapsing forms of multiple sclerosis (MS). It allows prescribers to submit the prescription while enrolling patients in Biogen support services, including copay assistance and treatment coordination. Accurate completion of this form helps avoid treatment delays and ensures smooth communication between the patient, prescriber, pharmacy, and Biogen support team. Start filling it out today to move your treatment forward without unnecessary delays.
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Benefits of The Tecfidera Enrollment Form
Tecfidera Copay & Financial Assistance
The form allows eligible patients to enroll in the Biogen Copay Program. This can significantly reduce out-of-pocket costs and make long-term treatment more affordable.
Insurance Verification and Approval
Including pharmacy and medical insurance information helps verify coverage quickly, reducing the risk of claim denials or coverage-related issues.
Biogen Support Services Enrollment
By signing the authorization section, patients can access Biogen’s support services, including treatment guidance, prescription coordination, and ongoing treatment assistance throughout their Tecfidera treatment.
Key Sections of The Tecfidera Patient Form
Patient Consent & Authorization
It covers authorization to share health information, enrollment in patient services, and optional marketing communications.
Patient Information Section
This section includes the patient’s basic information, such as their name, address, gender, date of birth, and contact details.
Prescriber Information
It specifies the prescriber’s name, address, state license number, NPI, and tax ID.
Insurance Details
This section includes the primary insurance name, group number, policy number, and the policyholder’s complete name.
Prescription Information
It describes the starter dose and maintenance dose, including the titration starter pack and refill options.
How To Complete The Tecfidera Start Form?
Authorization to Share Health Information: This section requires the patient or their representative to sign and date it to authorize the sharing of their health information and agree to the terms.
Patient Information: Choose the gender and fill in the patient’s full name, complete address, date of birth, email address, and language preference.
Statement of Medical Necessity: The prescriber must provide the appropriate ICD-10 diagnosis code, current or most recent therapy, patient’s height & weight, and any known allergies.
Prescriber Information: Write the prescriber’s name, complete address, contact details, NPI number, and tax ID.
Medical Benefit Details: Provide the primary insurance details, including policy number, group number, insurance company phone & fax numbers, and policyholder’s name.
Prescriber Authorization: The prescribing healthcare provider must sign the authorization section.
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Frequently Asked Questions
What is the Tecfidera start form?
It is used to start treatment with Tecfidera for adults diagnosed with relapsing forms of multiple sclerosis. It allows healthcare providers to submit the prescription and helps enroll the patient in Biogen support services.
Is patient consent mandatory to receive Tecfiera?
Signing the patient consent section is not necessary to receive Tecfidera. However, signing them allows patients to access Biogen support services, including copay assistance and prescription tracking.
How should the completed form be submitted?
The healthcare provider must fax the form to the fax number listed on the form.
Can the medication be delivered to my home address?
Of course, Tecfidera is typically shipped directly to the patient’s home through a certified specialty pharmacy.
What happens if the form is incomplete?
Missing information can delay prescription approval and treatment start, so all sections must be completed carefully.