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START PROGRAM FORM
To be completed in full, signed, and dated, then faxed to 8443947155.
For additional assistance, call 84INGREZZA (8446473992), 8 am 8 pm EST, M F.INSTRUCTIONS
12PATIENT INFORMATIONPRESCRIBER
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How to fill out ingrezza enrollment form
How to fill out ingrezza enrollment form
01
Step 1: Obtain the ingrezza enrollment form from the healthcare provider or pharmacy
02
Step 2: Fill out your personal information such as name, date of birth, and contact details
03
Step 3: Provide information about your insurance coverage or payment method
04
Step 4: Complete any medical history or current medication sections as required
05
Step 5: Review the form for accuracy and sign where indicated
06
Step 6: Submit the completed enrollment form to the appropriate party
Who needs ingrezza enrollment form?
01
Patients who have been prescribed ingrezza medication for the treatment of tardive dyskinesia
02
Individuals who are starting a new treatment plan with ingrezza and need to enroll in the program
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What is ingrezza enrollment form?
Ingrezza enrollment form is a form used to enroll in the Ingrezza Savings Program.
Who is required to file ingrezza enrollment form?
Patients prescribed Ingrezza medication are required to file the enrollment form.
How to fill out ingrezza enrollment form?
To fill out the form, patients need to provide their personal information, prescription details, and sign the form.
What is the purpose of ingrezza enrollment form?
The purpose of the form is to enroll patients in the Ingrezza Savings Program to help them save on their medication costs.
What information must be reported on ingrezza enrollment form?
Patients need to report their name, address, prescription details, and healthcare provider information on the form.
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