Edit, Download, and Sign the RemiStart® Patient Rebate Program Enrollment Form
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How do I fill this out?
To complete this form, start by selecting your enrollment type and filling in all required personal and insurance information. Confirm your eligibility and agreement to the terms. Submit the form via the designated fax or mail address.
How to fill out the RemiStart® Patient Rebate Program Enrollment Form?
1
Select your enrollment type.
2
Fill in personal and insurance information.
3
Confirm eligibility and agree to terms.
4
Sign the form.
5
Submit via fax or mail.
Who needs the RemiStart® Patient Rebate Program Enrollment Form?
1
Patients beginning treatment with REMICADE®.
2
Patients currently receiving REMICADE® treatment.
3
Patients with private or commercial health insurance covering REMICADE®.
4
Patients seeking financial assistance through the RemiStart® program.
5
Healthcare providers assisting patients with REMICADE® treatment.
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How do I edit the RemiStart® Patient Rebate Program Enrollment Form online?
Using PrintFriendly's PDF editor, you can easily fill out all required sections of this form. The editor allows you to input personal and insurance details with ease. Ensure to double-check and save your changes before submission.
1
Open the PDF in PrintFriendly's editor.
2
Fill in personal information.
3
Input insurance details.
4
Digitally sign the form.
5
Save and review the form before submission.
What are the instructions for submitting this form?
To submit the form, fax it to 877-234-3048 or mail it to Patient Rebate Program, 14001 Weston Parkway, Suite 103, Cary, NC 27513. Ensure all required sections are completed accurately. Always retain a copy of the form for your records.
What are the important dates for this form in 2024 and 2025?
The important enrollment date to note is December 31, 2016, which is the expiration date for new enrollments. Always check for updates.
What is the purpose of this form?
The purpose of this form is to enroll patients in the RemiStart® Patient Rebate Program for REMICADE®. It aims to provide financial assistance to eligible patients by reimbursing a portion of their medication costs. This form collects necessary personal and insurance information to determine patient eligibility and facilitate the rebate process.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for name, address, phone number, email, and date of birth.
- 2. Insurance Information: Requires details of the patient's private or commercial insurance plans.
- 3. Authorization: Patient's consent for sharing medical and insurance information.
- 4. Prescriber Information: Information about the prescribing physician and their practice.
What happens if I fail to submit this form?
Failure to submit this form will result in the patient not being enrolled in the RemiStart® program, thus losing access to financial assistance for REMICADE® treatment.
- Loss of Financial Assistance: Patients may have to bear the full cost of the medication without the rebate.
- Treatment Disruption: Increased financial burden may lead to interruptions in treatment.
How do I know when to use this form?
- 1. New REMICADE® Patients: Patients beginning treatment should use this form to enroll in the rebate program.
- 2. Existing REMICADE® Patients: Current patients should use this form to update their information and maintain enrollment.
Frequently Asked Question
How do I complete the RemiStart® Enrollment Form?
Fill out all required sections with personal and insurance information, sign, and submit via fax or mail.
Can I edit the form on PrintFriendly?
Yes, you can easily fill out and edit the form using PrintFriendly's PDF editor.
How do I sign the form?
Use the signature feature in PrintFriendly to digitally sign the form.
How can I share the completed form?
Use PrintFriendly's sharing options to email or send the completed form directly.
Who needs this form?
Patients undergoing REMICADE® treatment and their healthcare providers for financial assistance.
What information is required on the form?
Personal details, insurance information, and patient authorization.
Is private or commercial insurance necessary?
Yes, it is a requirement for the RemiStart® program.
When does the offer for this program expire?
The offer for new enrollment expires on December 31, 2016.
Can I save the form after editing?
Yes, you can save the form after completing and reviewing it on PrintFriendly.
How do I submit the form?
Submit the completed form via the designated fax or mail address provided.
