Tezspire Enrollment Form Download – Start Prescription Assistance
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Tezspire Enrollment Form |
Patient Support Program |
12 Page |
PDF, Fillable PDF |
Tezspire Enrollment Form
Accessing treatment for severe asthma can be challenging without proper support and requires support programs that simplify access, coverage, and affordability. The Tezspire enrollment form is used to help patients and healthcare providers connect with services like benefits verification, copay assistance, prescription support, and patient assistance programs. By completing this form, patients can get faster access to their prescribed therapy and financial resources. Start today by filling it out online, faxing it, or calling for assistance.
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Advantages Of Tezspire Enrollment Form
Direct Prescription Processing
Prescribers can complete and request that the prescribed Tezspire be processed accurately and sent to the appropriate specialty pharmacy or medical facility, reducing the chances of errors.
Benefits Verification
The Tezspire enrollment form allows healthcare providers to confirm insurance coverage quickly, helping patients understand what their health plan covers and what costs they can expect.
Financial Relief and Predictability
By using the co-pay or patient assistance programs, the patients can manage medication costs more effectively, allowing them to focus on treatment rather than worying about affordability.
Key Sections of The Tezspire Enrollment Form PDF
Patient Details Section
This section contains the patient’s name, address, date of birth, and caregiver or legal representative information.
Insurance Details
The insurance section includes primary and secondary insurance plans, providing details such as provider, phone number, cardholder information, group number, PCN, and policy number.
Clinical Information
It includes diagnosis codes and relevant treatment verification information.
Product Selection & Acquisition
This section allows prescribers to choose the preferred formulation and method of delivery.
Prescriber Information & Prescription
It gathers prescribers’ details, including the prescriber’s name, practice name, phone number, address, state license number, and prescription authorization.
Fast Start Program
It lets patients start their prescribed Tezspire treatment if the insurance process is pending.
Co-Pay Enrollment
This section allows commercially insured patients to start reduced out-of-pocket medication.
Patient Assistance Program Pre-Screening
Patients who are financially challenged or uninsured can check their eligibility by providing additional information, such as their residence, the number of family members, and their total monthly and yearly income.
How To Complete The Tezspire Together Enrollment Form?
Patient Information: Enter the patient’s full name, date of birth, gender, complete address, email address, preferred form of communication, phone number, and language preference.
Insurance Information: Provide the insurance details, including insurance type, primary insurance provider, phone number, cardholder name, cardholder date of birth, policy number, group number, pharmacy BIN & PC, primary pharmacy insurance, and secondary insurance details (if applicable).
Clinical Information: Provide the ICD-10 diagnosis code and known allergies.
Specialty Pharmacy: Fill in the patient’s name, date of birth, and preferred network specialty pharmacy.
Product Selection & Acquisition Method: Choose the dosage, frequency, product formulation, administrative site, and acquisition method.
Prescriber Information: Specify the prescriber’s name, office name, tax ID number, practice name, NPI number, state license number, site NPI number, Medicare provider number (PTAN), Medicaid provider number, and address.
Prescription Information: Indicate the required enrollment, device type, and preferred shipping address.
Fast Start Enrollment: The newly prescribed Tezspire and commercially insured patients can opt into the fast start program to initiate treatment while insurance approval is pending.
Co-Pay Enrollment: The patients with private/commercial insurance can apply for the Teszspire Together Copay Program. The patients with any Government-provided coverage, such as Medicare, Medicaid, or Tricare, are not eligible for this program.
Patient Assistance Program Pre-Screening: If uninsured, provide the residency and financial information, including household income and number of household members.
Consent & Authorization: Sign and date the form to authorize the form.
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Frequently Asked Questions
What is the purpose of the Tezspire enrollment form?
This form is used to collect necessary information about the patient, the insurer, the prescriber, and the medical and clinical prescription. It brings patients and healthcare providers together with services, such as benefits verification, co-pay assistance, prescription support, and patient assistance programs.
Do I need to provide a medical record with this form?
No medical and clinical records are necessary to be attached to the form. Only the requested information should be completed accurately.
Can caregivers complete the form on behalf of the patient?
Of course, legal representatives or caregivers can complete, sign, and date the form on behalf of the patient.
What happens after I submit my form?
The Tezspire program verifies insurance, processes prescription support, and determines eligibility for co-pay or financial assistance programs.
Can an uninsured patient use this form?
Yes, uninsured patients can complete the Patient Assistance Program Pre-Screening section to determine if they qualify for free medication through the Amgen Safety Net Foundation.
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