To submit this Enrollment Form, you can fax it to CVS Specialty at 1-800-323-2445 or email it directly to Customer.ServiceFax@CVSHealth.com. Make sure to attach any relevant prescriptions and insurance cards to expedite processing. For further assistance, you can contact CVS Specialty at 1-800-237-2767 and ensure that all information is complete to avoid delays.

Important dates for this form include the review and submission deadlines for patient enrollments. It is crucial to stay updated on any changes in medication coverage. Regularly check with your provider for any upcoming changes relevant to this Enrollment Form.

The purpose of the Specialty Pharmacy Services Enrollment Form is to collect essential patient and prescriber details necessary for processing specialty medication prescriptions. This form streamlines the referral and approval process, ensuring patients receive timely access to their medications. By maintaining accurate records, CVS Specialty aims to improve patient care and coordination.

• 1. Patient Information: Collects essential details about the patient such as name, date of birth, and contact information.
• 2. Prescriber Information: Gathers the prescribing doctor's details to validate the medication request.
• 3. Insurance Information: Requires submission of insurance details to facilitate coverage verification.
• 4. Diagnosis and Clinical Information: Captures the clinical justification for the medication through diagnosis codes.
• 5. Prescription Information: Documents the prescribed medication details including dosage and instructions.
• 6. Prescriber Signature: Requires the prescriber's signature to authorize the medication request.

Failure to submit this form can result in delays in obtaining necessary medications for patients. It may hinder the approval process with insurance providers, impacting timely access to therapy. Patients may experience interruptions in care if prescriptions are not filled promptly.

• Delayed Medication Access: Patients may not receive their medications on time, affecting their health.
• Insurance Processing Delays: Incomplete submissions can lead to slower approval processes with insurance.
• Increased Healthcare Costs: Delays in prescription fulfillment may result in higher out-of-pocket expenses.

• 1. When initiating specialty pharmacy services: Use this form to start the enrollment process for specialty medications.
• 2. For prescription prior authorization: Submit the form to ensure the insurance covers the necessary medications.
• 3. When coordinating care: Healthcare providers should utilize this form for providing cohesive care.