Xelsource enrollment form 2022-2026

1. Click ‘Get Form’ to open the xelsource enrollment form 2022 in the editor.
2. Begin by filling out the Patient Information section. Enter the patient's name, date of birth, address, and primary phone number. Ensure all details are accurate for effective communication.
3. In the Insurance section, provide information about the patient's primary prescription insurance. Include policy ID, policy holder's name, and any secondary coverage if applicable.
4. Complete the Patient Authorization section by checking relevant boxes and signing where indicated. This authorizes XELSOURCE to handle protected health information.
5. Fill in the Prescriber Information with details about the prescribing doctor, including their name, specialty, and contact information.
6. In the Clinical Information section, document any allergies and current medications. This is crucial for ensuring safe treatment options.
7. Finally, review all entries for accuracy before submitting. Use our platform’s features to save or print a copy for your records.

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