Acthar Enrollment Form Printable PDF Download
Acthar Enrollment Form
Acthar Gel (Repository Corticotropin Injection) is a prescription medication such as lupus, nephrotic syndrome, sclerosis relapses, rheumatoid arthritis, and infantile spasms. Its specialised usage often requires additional paperwork, starting with the enrollment form.The Acthar Enrollment Form is vital in accessing this medication and helps treat severe medical conditions.
You can download acthar form by clicking the download button below. Moreover, you will learn how to fill out this form accurately, its purpose, and additional details for streamlining the enrollment process.

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Purpose of Acthar Enrollment Form Fillable
Acthar Latest Enrollment Form is essential for various purposes when accessing medication from specialised Acthar Gel. It ensures the following key objectives,
Patient Information Collection
Acthar form ensures the collection of all essential information about the patient, such as personal, insurance, and medical information, to understand the necessity of the prescription.
Insurance Verification
It ensures that the patient has enough coverage of the insurance policy before enrolling in the costly medication Acthar Gel.
Eligibility for Patient Support Program
The accurate completion of this form ensures they fulfill the eligibility criteria for the patient support program to get personalised guidance and financial assistance.
Coordination with Specialty Pharmacies
It ensures transparent communication between healthcare providers, patients, and speciality pharmacies that disperse Acthar gel.
How To Download a Fillable Acthar Enrollment Form
Visit Forms Dude
- Step 1: Type www.formsdue.com in any web browser to visit the homepage.
- Step 2: Type the form’s name (Acthar Enrollment Form) in the search bar.
- Step 3: Search for the fillable blank PDF form in the result.
- Step 4: Click the Download Acthar Enrollment Form button to save it instantly.
- Step 5: Open and fill out the form using the PDF editor.
- Step 6: Fortunately, you can fill out this form here and press the print button for a printout immediately.
- Step 7: Re-check the filled form and submit it.
Checklist for Acthar Enrollment Form Submission
These instructions will guide you to complete the form accurately:
1- Patient Information
In this section of Acthar Enrollment Form you must write the patient’s name, date of birth, mobile number, phone number, preferred language (other than English), address, city, state, zip code, email address, and gender.
2- Insurance Information
You must write the pharmacy benefit provider’s name, subscriber number, group number, and phone number. Also, write the primary medical insurance name, subscriber number, group number, and phone number.
3- Prescriber Information
Write the HCP (Healthcare Provider) name, specialty, address, city, state, zip code, state license number, NPI number, Tax ID number, office contact name, phone number, fax number, and email address.
4- Prescription & Commercial Starter Program
The healthcare provider will mention the injection dosage and its frequency. Also, enrolling the patient in the patient support program is recommended.
5- Prescriber Signature
The prescriber will sign on Acthar Enrollment Form page 1 with the date.
6- Diagnosis and Medical Information
In this section, write the patient’s name and date of birth. Also, the HCP will tick the diagnosis code boxes, including the history of corticosteroid use, concurrent medication, and relevant treatment history.
7- Patient Authorization(s)
The patient will write his/her name and sign the form with the date to allow the Acthar patient support team to work with the insurance provider, pharmacy, and advocacy organisation.
Additional Notes for Acthar Form Submission
You must consider these additional details while filling out this enrollment form to avoid complications:
Provide Accurate Information
You must provide accurate information on this form and re-check it after completion to avoid delays in the process.
Insurance Denials
You must understand the Acthar gel medication insurance coverage policy. However, some insurance policies are not covered by Acthar, so participate in the patient support program to assist with financial solutions.
Transparent Communication with Your Provider
You must check that your healthcare provider accurately completes his portion of this form to support the process’s approval.
Record Maintenance
You must keep a copy of this form after completion to maintain the record to provide on reference in future.
FAQs
What is the Acthar Enrollment Form?
It is an essential document to enrol for accessing the Acthar gel medication and get the prescription treatment for various severe medical conditions. It ensures transparency between healthcare providers, patients, and specialty pharmacies.
How Long Does It Take to Process Acthar Gel Enrollment Form?
The processing time varies due to complexity and number of application forms. However, completing the process takes a few days and a few weeks.
Can I Complete This Enrollment Form Online?
You must look for this fillable form above and complete all sections online accordingly.
What if My Insurance Denies Coverage for Acthar Gel?
You must participate in the patient support program and get financial assistance after denials of insurance coverage.