EYLEA4U Enrollment Form PDF – Download and Print Today

EYLEA4U Enrollment Form

EYLEA (aflibercept) injection is a prescription medication for severe retinal conditions. Its timely and effective treatment can change the whole lives of all eligible patients. You must complete the Eylea4u Enrollment Form to participate in the Eylea program to access financial assistance, navigate insurance requirements, and connect with patient resources.

Click the download button below to save this fillable form on your device. Moreover, you will know its importance, how to complete this form, and additional details to avoid mistakes.

Importance of EYLEA4U Patient Enrollment Form

It is a legal document designed to support patients to access the patient support program. It helps the patients in the following scenarios.

Financial Assistance

The patient will receive financial assistance to mitigate the costly treatment burden. The Eylea support team members will guide the patient through the treatment plan.

Insurance Verification

This form helps identify a patient with adequate insurance coverage compatible with the Eylea program.

Educational Resources

The Eylea support team will guide the patients about the dosage, treatment plan, and side effects.

Coordinating Care Services

It helps coordinate transparent communication between healthcare providers, patients, and specialty pharmacies.

How To Download EYLEA4U Injection Enrollment Form PDF

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  • Step 1: Type www.formsdue.com in any web browser to visit the homepage.
  • Step 2: Type the form’s name (EYLEA4U Enrollment Form) in the search bar.
  • Step 3: Search for the fillable blank PDF form in the result.
  • Step 4: Click the download 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.

Quick Steps to Successfully Complete the Eylea4u Patient Enrollment Form

Follow the given instructions carefully to complete the form with accuracy:

1- Patient Information

Write the patient’s name, gender, date of birth, phone number, email address, complete address (street, city, state, and zip code), and preferred language.

2- Insurance’s Information

If the patient has an insurance policy, write the payer’s name, phone number, policyholder’s name, policy number, and group number for the primary and secondary insurance policy.

3- Financial Information

If the patient has no insurance policy, he/she can apply for the Patient Assistance Program (PAP) by providing the following information. Write the number of people living in your household and tick the box for total annual household income.

4- Patient Authorization

In this section, the patient will sign the form with the date.

5- Physician Authorization

The physician will sign here with the date to validate the process.

6- Diagnosis

The prescriber will tick the boxes for the required diagnosis.

7- Prescribing Physician Information

Write the facility name, physician’s name, email address, phone number, fax number, physician’s specialty, address, city name, state name, and zip code. Also, write the physician’s state license number, DEA number, PTAN number, Tax ID number, NPI number, and site entity NPI.

8- Office Contact Information

Write the primary office contact name, phone number, fax number, and email address.

Key Points to Consider While Filling Out the Eylea4u Enrollment Form

These additional details must be considered while filling out this form to ensure accuracy and mitigate the chances of errors.

Avoid Incomplete Information

You must provide complete and accurate information on this form to ensure accuracy. Re-check the form after completion to ensure no fields remain blank.

Missing Signatures

The signatures of the patient and the healthcare provider are essential to validate the form to process the eligibility criteria.

Attach Supporting Documents

To strengthen the case, you must attach your primary and health insurance card to this form. If any required document is missing, it can cause delays or rejection.

Record Maintenance

Keeping a copy of this form after completion is strongly suggested to maintain your record.

FAQS

What is the Eylea4u Enrollment Form?

It is a standard form to participate in the Eylea program to get prescription medication treatment for all severe retinal conditions. It also helps to get financial assistance and care through the treatment process.

What Happens After Eylea Program Form Approval?

The approved patients will access the enrollment of the Eylea4u program to receive financial assistance and additional resources to receive benefits during treatment.

How Often Must the Form be Updated?

This form needs to be completed once during the enrollment process. However, it can be updated if the insurance policy changes.

Can Uninsured Patients Apply for the Eylea4u Enrollment Program?

Yes, they can participate in the patient support program and get financial assistance or free medication through the program.

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