ViiVConnect Patient Enrollment/Authorization Form 2016 free printable template

2016 ViiV Healthcare group of companies. All rights reserved. Produced in USA. 704080R0 August 2016. Form from www. needymeds. org Reset Form Patient Enrollment Form ViiVConnect is an assistance program that provides access to ViiV Healthcare medicines to eligible patients. For assistance with any questions please call 1-844-588-3288 toll-free Monday through Friday 8am to 8pm ET. If an authorized representative signs for the patient please indicate relationship to the patient. By signing...

How to fill out viivconnect enrollment form

How to fill out ViiVConnect Patient Enrollment/Authorization Form

1. Begin by downloading the ViiVConnect Patient Enrollment/Authorization Form from the official ViiV Healthcare website.
2. Fill out the patient's personal information, including full name, address, date of birth, and contact number.
3. Provide information about the patient's insurance coverage, including the name of the insurance provider and policy number.
4. Complete the section regarding the patient's medical history and current medications, if applicable.
5. Sign and date the form to authorize release of information to ViiVConnect.
6. Include any necessary supporting documents, such as a copy of the insurance card or medical prescriptions.
7. Submit the completed form and supporting documents via fax, email, or mail as instructed on the form.

Who needs ViiVConnect Patient Enrollment/Authorization Form?

1. Patients who are prescribed ViiV Healthcare medications and wish to access support services.
2. Patients who require financial assistance or insurance navigation support for their treatment.
3. Healthcare providers who need to facilitate patient access to ViiVConnect resources for their patients.

People Also Ask about

How do I contact ViiV connect?

Our Access Coordinators are here to assist you with your questions and needs. Call 1-844-588-3288 (toll free), Monday–Friday, 8AM–11PM (ET). Multilingual options are available.

What is the fax number for ViiVConnect?

Complete, sign, and electronically submit all pages of this form and applicable corresponding documents (including the prescription) through the ViiVConnect Provider Portal, or fax to 1-844-208-7676 (toll-free). For assistance, please call 1-844-588-3288 (toll-free), Monday through Friday, 8am to 11pm (et).

What is the phone number for ViiV healthcare?

1800 499 226. If you are a patient and have experienced an unexpected event when taking one of our medications please speak to your healthcare professional as soon as possible.

What is ViiV connect?

What Is ViiVConnect? ViiVConnect provides comprehensive information to help healthcare professionals, pharmacists, patient representatives, and patients explore ways to access prescribed ViiV Healthcare medications.

What is the Cabotegravir assistance program?

APRETUDE (cabotegravir) Savings Program* The APRETUDE Savings Program* helps eligible, enrolled patients with their out-of-pocket costs for prescribed APRETUDE. The program offers up to $7500 in product assistance and up to $350 in administrative out-of-pocket expenses every calendar year for eligible patients.

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What is ViiVConnect Patient Enrollment/Authorization Form?

The ViiVConnect Patient Enrollment/Authorization Form is a document used to enroll patients in the ViiVConnect program, which provides access to support services, medication, and resources for those living with HIV.

Who is required to file ViiVConnect Patient Enrollment/Authorization Form?

The ViiVConnect Patient Enrollment/Authorization Form must be filed by healthcare providers on behalf of patients who are seeking access to ViiV Connect services, typically those being treated for HIV.

How to fill out ViiVConnect Patient Enrollment/Authorization Form?

To fill out the ViiVConnect Patient Enrollment/Authorization Form, the healthcare provider needs to provide patient information, including personal details, insurance information, and specific healthcare needs. It is important to complete all required sections accurately.

What is the purpose of ViiVConnect Patient Enrollment/Authorization Form?

The purpose of the ViiVConnect Patient Enrollment/Authorization Form is to facilitate the enrollment of patients into the ViiV Connect program, ensuring they receive necessary support and resources for their treatment.

What information must be reported on ViiVConnect Patient Enrollment/Authorization Form?

The information that must be reported on the ViiVConnect Patient Enrollment/Authorization Form includes the patient's name, contact information, date of birth, insurance details, treatment history, and any specific requests for services.