HUMIRA Complete Enrollment and Prescription Form
This file contains details and instructions about enrolling in the HUMIRA Complete program, along with information on prescription usage and safety. It provides a comprehensive guide for getting started with HUMIRA treatment, including insurance navigation, prescription fulfillment, and injection training. It also includes important safety information and how to fill out the enrollment and prescription form.
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How do I fill this out?
To fill out this form, follow the instructions on each section carefully. Ensure that all required fields are completed accurately. If you need assistance, a Nurse Ambassador is available to help guide you through the process.
How to fill out the HUMIRA Complete Enrollment and Prescription Form?
1
Provide the patient's information including name, address, and contact details.
2
Attach available insurance cards and fill in the insurance information.
3
Have a healthcare professional complete the diagnosis section.
4
Provide prescriber information and indicate if you want copies of specific documents.
5
Include any relevant clinical information and attach necessary clinical/office notes.
Who needs the HUMIRA Complete Enrollment and Prescription Form?
1
Parents or legal guardians of children prescribed HUMIRA, to enroll in the HUMIRA Complete program.
2
Healthcare professionals, to provide necessary diagnosis and prescriber information.
3
Insurance specialists, to assist in navigating insurance processes for HUMIRA treatment.
4
Patients recently diagnosed with conditions treated by HUMIRA, to understand treatment and safety information.
5
Patients needing step-by-step guidance for administering HUMIRA injections at home.
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What are the instructions for submitting this form?
Submit the completed form by faxing it to 1.678.727.0690. Ensure to attach all necessary insurance cards and provide accurate patient and prescriber information. For any assistance, contact HUMIRA support at 1.800.4HUMIRA (1.800.448.6472). My advice is to review all information carefully before submission to avoid any delays.
What are the important dates for this form in 2024 and 2025?
Ensure to call the Specialty Pharmacy at least 2 weeks before your child's first injection. Submit the completed form as soon as possible for timely enrollment and processing.
What is the purpose of this form?
The purpose of this form is to enroll patients in the HUMIRA Complete program and provide a detailed guide for HUMIRA treatment. The form collects necessary patient, insurance, and prescriber information for accurate processing. Additionally, it offers important safety information and instructions for administering HUMIRA injections at home.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for the patient's name, address, contact details, and additional relevant personal information.
- 2. Insurance Information: Requires attaching insurance cards and filling in details about medical and prescription insurance.
- 3. Diagnosis: To be completed by a healthcare professional, including diagnosis details and ICD-10 code.
- 4. Prescriber Information: Includes fields for the prescriber's name, contact details, and office information.
- 5. Clinical Information: Collects details about prior therapies, concomitant medications, TB test results, weight, and drug allergies.
What happens if I fail to submit this form?
Failing to submit this form may delay or prevent enrollment in the HUMIRA Complete program, impacting your access to support and resources.
- Delayed Treatment: Without submission, enrolling in the program will be delayed, postponing the start of HUMIRA treatment.
- Lack of Support: Failure to submit will result in missing out on valuable support from Nurse Ambassadors and other resources.
- Insurance Navigation: Patients may face difficulties in navigating insurance processes without support, potentially increasing out-of-pocket costs.
- Missed Savings Opportunities: Missing out on potential savings options provided by the HUMIRA Complete program.
- Incomplete Medical Records: Failing to submit may result in incomplete medical records, impacting treatment decisions made by healthcare providers.
How do I know when to use this form?
- 1. Starting HUMIRA Treatment: For patients and guardians beginning a prescribed HUMIRA treatment plan.
- 2. Navigating Insurance: To get assistance from Insurance Specialists in navigating coverage and potential savings.
- 3. Injection Training: For detailed guidance on administering HUMIRA injections at home.
- 4. Safety Information: To understand potential risks and side effects associated with HUMIRA treatment.
- 5. Program Enrollment: To ensure enrollment in the HUMIRA Complete program for ongoing support and resources.
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What information is required in the patient section?
The patient section requires the patient's name, address, contact details, and additional relevant information.
Do I need to attach insurance cards?
Yes, attach available insurance cards and fill in the necessary insurance details.
Who should fill out the diagnosis section?
A healthcare professional should complete the diagnosis section with the relevant information.
What prescriber information is needed?
Provide the prescriber's name, office contact details, and indicate if you want specific document copies.
How do I access injection training videos?
Visit HUMIRA.com/training or use your phone's camera to scan the QR code provided in the document.
