Oxervate patient enrollment form 2026

1. Click ‘Get Form’ to open the oxervate patient enrollment form in the editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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!