ViiVConnect Patient Enrollment/Authorization Form 2023-2026 free printable template
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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...
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How to fill out ViiVConnect Patient EnrollmentAuthorization Form
How to fill out ViiVConnect Patient Enrollment/Authorization Form
01
Gather necessary patient information, including name, date of birth, and contact details.
02
Fill out the insurance information section, including policy number and provider details.
03
Provide medical history and current medication list as requested.
04
Complete the authorization section for ViiV Healthcare's use of information.
05
Sign and date the form at the bottom.
06
Submit the form via the specified method (fax, mail, or online submission).
Who needs ViiVConnect Patient Enrollment/Authorization Form?
01
Patients who are prescribed ViiV Healthcare medications.
02
Healthcare providers who need to initiate patient support services.
03
Individuals seeking assistance with medication access and insurance verification.
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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?
ViiVConnect Patient Enrollment/Authorization Form is a document used to enroll patients in ViiV Healthcare's support programs, providing access to treatment and resources for managing HIV.
Who is required to file ViiVConnect Patient Enrollment/Authorization Form?
Healthcare providers and authorized agents are required to file the ViiVConnect Patient Enrollment/Authorization Form on behalf of patients seeking access to ViiV Healthcare services and support.
How to fill out ViiVConnect Patient Enrollment/Authorization Form?
To fill out the ViiVConnect Patient Enrollment/Authorization Form, provide the patient's personal information, insurance details, and medical history as required, while ensuring all fields are completed 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 ViiV programs, ensuring they receive appropriate support, resources, and access to medications.
What information must be reported on ViiVConnect Patient Enrollment/Authorization Form?
The form must report the patient's identification details, insurance information, treatment history, and any relevant healthcare provider information necessary for processing the enrollment.
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