To submit this form, complete all required fields and verify that your information is accurate. Send the completed form to ViiVConnect either by email at support@viivconnect.com, by fax at 1-844-208-7676, or by mailing to ViiVConnect, PO Box 5490, Louisville, KY 40255. Ensure you keep a copy for your records and check for any follow-up communications from ViiVConnect.

Important dates for using this form include submission deadlines for insurance benefits verification in early 2024. Ensure timely enrollment to access ViiVConnect patient services without delays. For additional support, refer to future updates on the ViiVConnect website.

The purpose of this form is to facilitate patient enrollment in ViiVConnect, a service designed to help individuals access ViiV Healthcare medications, including CABENUVA. By completing this form, patients provide essential information that helps verify insurance coverage and eligibility for assistance programs. This streamlined process ensures patients receive the medications they need without unnecessary delays or complications.

• 1. Patient Information: Includes fields for the patient's name, address, contact details, and date of birth.
• 2. Insurance Information: Requests details about the patient's insurance plan, including policyholder name and plan type.
• 3. Medication Information: Section for listing current medications and allergies, including responses about the prescribed medication.
• 4. Prescriber Information: Requires details of the prescribing healthcare provider, including contact information and signatures.
• 5. Patient Authorization: Includes consent fields where the patient authorizes the disclosure of their medical information.

Failure to submit this form may result in delays in receiving necessary medications and assistance services. Additionally, patients may miss crucial benefits provided through ViiVConnect, affecting their access to medication. It is important to ensure the form is completely and accurately filled out to avoid complications in processing.

• Access Delays: Patients may face delays in obtaining their prescribed medications.
• Insurance Verification Issues: Miscommunication regarding coverage may arise.
• Missed Opportunities: Patients might miss essential support services available through ViiVConnect.

• 1. New Patient Enrollment: For patients newly prescribed CABENUVA seeking assistance.
• 2. Insurance Claim Verification: If patients need their insurance benefits verified before medication dispensing.
• 3. Patient Support Programs: When accessing additional patient resources or financial assistance.