Gilenya Start Form: Download, Complete, and Submit
Gilenya Start Form
Gilenya (fingolimod) is a prescription medication for treating severe relapsing-remitting disease (multiple sclerosis) in adults. Completing the Gilenya Start Form is crucial to meeting the eligibility criteria for the patient assistance program offered by Novartis manufacturers.
You must click the download button below to access the printable PDF form. Moreover, you will learn its importance, how to complete this fillable form accurately, and essential tips to avoid treatment delays.
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Importance of the Gilenya Go Program Start Form
It is an essential document required by the patients, healthcare providers, and Novartis, the manufacturer of Gilenya medication. It plays a critical role in the following scenarios,
Patient Enrollment
It helps the patients enroll in the Gilenya patient support program for prescription medicine.
Financial Asssistance Program
Novartis, the manufacturer of Gilenya, offers financial assistance to eligible patients through copay and patient assistance programs.
Facilitate Insurance Approvals
It verifies the insurance details and helps in the insurance coverage approval process, facilitating the patient’s access to more benefits.
Support Services
The Novartis support team educates on medication, its side effects, and medicine delivery.
How To Download Gilenya Start Form PDF
Visit Forms Dude
- Step 1: Type www.formsdude.com in any web browser to visit the homepage.
- Step 2: Type the form’s name (Gilenya Start 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.
Step-by-Step Instructions for Filling Out the Blank Gilenya Patient Assistance Form
The following instructions will help you to complete this form accurately.
1- Patient Information
Write the patient’s complete name, gender, date of birth, phone number, email address, and full residential address.
2- Insurance Information
Write the caregiver’s name, insurance name, cardholder’s name, ID number, group number, phone number, prescription insurance name, ID number, and phone number.
3- Patient Authorization
The patient must sign here with the date to authorize the information sharing with the Gilenya team.
4- Prescriber Information
Write the prescriber’s name, complete address, phone number, fax number, medical license number, and NPI number. Also, write the office contact name, phone number, and email address.
5- Diagnosis and Prescription
The healthcare provider will tick the starter product’s diagnosis, medicine prescription, and shipping address.
6- Prescriber Authorization
The physician will sign here with the date to start the process.
Additional Details While Filling Out the Gilenya Patient Start Form
The patient must consider these additional details if they face any error or delays in enrollment.
Provide Accurate Information
The patient and healthcare provider must provide accurate information on this form to ensure accuracy and avoid delays.
Attach Supporting Documents
You must attach all required supporting documents to this form. These documents include the patient’s identity, front and back copies of insurance cards, and medical history.
Record Keeping
After completing this form, you must keep a copy for your records.
Financial Concerns
Consult with the Gilenya support team and the healthcare provider to ensure participation in the support program for discounted medication.
FAQs
What is a Gilenya Start Form?
It is a standard document that contains the details of the patient, healthcare provider, and insurance coverage. It bridges the patient, healthcare provider, and specialty pharmacies to streamline the process. Accurately completing this form ensures participation in the support program to get free medication.
What are the Side Effects of Gilenya Medication?
The common side effects of Gilenya are headache, back pain, fatigue, cough, diarrhea, and elevated liver enzymes. However, the rare side effects include infections, heart issues, liver damage, and macular edema.
What are the Precautions and Monitoring Steps Before Starting Gilenya?
The patient must undergo heart monitoring, eye exams, and blood tests to check the possible heart rate change, macular edema, and liver functions.
How Can I Submit the Gilenya Patient Enrollment Form?
After completion, you can submit it through fax, email, physician’s office, and online portal.