Home
Forms Library
Oxervate enrollment form

Oxervate patient enrollment form 2026

oxervate enrollment form Preview on Page 1

See details

4.8 out of 5

37 votes

The document is an OXERVATE™ Patient Enrollment Form that outlines the process for prescribing and enrolling patients in treatment with OXERVATE, an ophthalmic solution. It includes sections for patient information, treatment details, insurance information, and patient authorization for sharing health information with Dompé Connect to Care. The form must be completed and faxed to the designated contact for processing prescriptions and facilitating patient support services.

Here's how it works

01. Edit your oxervate enrollment form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send oxervate patient enrollment form via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out oxervate patient enrollment form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the oxervate patient enrollment form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, address, and contact numbers. Ensure all fields are completed accurately.
In the 'Treatment Information / Prescription' section, your physician will need to select the treated eye(s) and check applicable ICD-10 codes. Make sure this part is filled out correctly as it requires physician input.
Complete the 'Patient Insurance Information' section by checking all relevant insurance plans and providing policy holder details. This ensures that coverage is verified for treatment.
Review the 'Patient Authorization for Dompé Connect to Care' section carefully. The patient or guardian must sign and date this authorization to allow sharing of health information.
Finally, ensure that all sections are complete before submitting. Use our platform's features to save your progress and easily fax the completed form to Dompé Connect to Care.

Start using our platform today for free to streamline your oxervate patient enrollment process!

See more oxervate patient enrollment form versions

We've got more versions of the oxervate patient enrollment form form. Select the right oxervate patient enrollment form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (37 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a patient enrollment form?

A Hospital Patient Registration Form is a form template designed to streamline the process of collecting patient details before their stay in the hospital.

Does oxervate need to be refrigerated?

Note: After the vial adapter is connected to the vial, OXERVATE can be stored in the refrigerator between 36F to 46F (2C to 8C) for up to 12 hours. If needed, the OXERVATE with the connected vial adapter may be stored at room temperature up to 77F (25C).

How do you get Oxervate?

To begin the process, you simply sign the OXERVATE prescription enrollment form at your doctors office. Once insurance coverage has been determined, you can expect a welcome call from Domp CONNECT to Care within 24 hours after they receive the enrollment form from your doctor.

How much does oxervate cost?

Patients will usually go through 28 vials of Oxervate in a 4-week period, and the typical treatment course lasts for 8 weeks. The list price for Oxervate is $1,732 per vial, making the cost for a typical treatment course $96,992.

Where can I order oxervate?

Please add this phone number to your contacts so you dont miss this important call: 1-877-422-4412. Once approved for financial assistance, you will be contacted by Accredo, a specialty pharmacy, to coordinate your biweekly shipments of OXERVATE to your home or preferred shipping address.

oxervate patient assistance program

OXERVATE Patient assistance program Oxervate cost OXERVATE Prescribing information Why is Oxervate so expensive Dompé CONNECT to Care enrollment form How to prescribe OXERVATE OXERVATE pharmacy Is Oxervate covered by Insurance