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How do I fill this out?
To fill out this form, start by providing your personal details in the Patient Enrollment section. Next, ensure you have your prescription insurance information ready for documentation. Finally, select the optional services you wish to receive and sign the required sections.
How to fill out the Taltz Together Enrollment for Ixekizumab Injection?
1
Read the instructions carefully before starting.
2
Fill in your personal and insurance details accurately.
3
Select any optional services you wish to enroll in.
4
Sign the form where indicated to validate it.
5
Fax the completed form to the designated number.
Who needs the Taltz Together Enrollment for Ixekizumab Injection?
1
Patients prescribed with Taltz who want assistance in obtaining their medication.
2
Healthcare providers who need to enroll their patients in the Taltz Together program.
3
Individuals seeking financial support to cover medication costs.
4
Patients looking for training on how to administer injections.
5
Users needing disposal assistance for sharps after injections.
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What are the instructions for submitting this form?
To submit the Taltz Together Enrollment Form, fill out all required fields accurately and ensure both the Patient and Prescriber sections are signed. Fax the completed form to 1-844-344-8108 as the primary submission method. For assistance, you can contact Taltz Together at 1-844-TALTZ-NOW.
What are the important dates for this form in 2024 and 2025?
Currently, specific important dates for the Taltz Together enrollment form for 2024 and 2025 are not outlined in the document. Please consult with Taltz Together for any updates. Keep an eye on communication for changes regarding deadlines and required submissions.
What is the purpose of this form?
The purpose of this form is to facilitate access to Taltz, a medication for certain conditions. It helps patients enroll in the Taltz Together program to receive necessary support. By completing this form, individuals can access financial assistance and training for medication administration.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: Collects the first name, middle initial, and last name of the patient.
- 2. DOB: Requires the date of birth in MM/DD/YYYY format.
- 3. Address: Documents the patient's residential address.
- 4. Insurance Information: Captures details related to the patient's prescription insurance.
- 5. Signature of Patient: Requires the patient's signature to validate the form.
What happens if I fail to submit this form?
If you fail to submit the form correctly, you may experience delays in receiving necessary support and services. Incomplete submissions can prevent you from accessing financial aid and training. It's crucial to follow the instructions and ensure all required sections are filled out.
- Inadequate Support: You may not receive the support needed for prescribed medications.
- Delayed Processing: Incomplete forms can lead to significant delays in processing requests.
- Insurance Issues: Failure to provide complete insurance information may result in denial of benefits.
How do I know when to use this form?
- 1. To Access Medication: Use this form to ensure you can obtain Taltz as prescribed.
- 2. For Financial Support: Enroll for financial aid that can ease the burden of medication costs.
- 3. To Receive Training: Get the necessary training for administering Taltz injections appropriately.
Frequently Asked Question
How do I fill out the Taltz Together enrollment form?
Complete the patient and prescriber sections with accurate information and sign where indicated.
What options can I select for Taltz Together services?
You can select benefits investigation support, co-pay savings, and injection training among others.
How do I submit the completed form?
Fax the signed form to 1-844-344-8108.
Can I edit the PDF directly on PrintFriendly?
Yes, you can easily edit the PDF in your browser before downloading.
Is assistance available if I have trouble with the form?
You can call Taltz Together at 1-844-TALTZ-NOW for support.
What if I do not have insurance?
You can still apply for assistance through the Taltz Together program.
Can I sign the PDF electronically?
Yes, you can add your signature digitally using PrintFriendly.
What is the purpose of the Patient HIPAA Authorization?
It allows Lilly to obtain necessary health information to assist you.
How do I ensure my information is accurate?
Double-check all entries for completeness and correctness before submission.
What happens if I miss signing the form?
Not signing will lead to an incomplete submission and delays in your services.
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