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Rheumatology enrollment form 2025

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The document is a comprehensive Rheumatology Enrollment Form designed for patients undergoing treatment for various rheumatic conditions. It includes sections for patient and prescriber information, insurance details, medical history with specific diagnoses and ICD-10 codes, prescription information for multiple medications, and authorization for pharmacy representatives to manage insurance prior authorization processes. The form emphasizes the need for detailed medical data to facilitate the prescription process.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (47 Votes)

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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 the fax number for Taltz together?

To enroll in the Taltz Together program, simply fax your completed enrollment form to 1-844-344-8108.

What are the entry requirements for rheumatology?

Requirements You must have completed Basic Specialist Training in the relevant specialty (or an equivalent programme) by the start date for HST. You must have achieved a relevant postgraduate qualification such as MRCPI in General Medicine, General Paediatrics or Obstetrics and Gynaecology.

What is the fax number for Taltz?

To submit to Lilly Support Services, please fax the completed enrollment form to 1-844-344-8108 or upload online at patientsupportnow.org with code 8443448108.

What is the fax number for vivitrol together?

FAX COMPLETED FORM TO: 1-877-329-8484. QUESTIONS? CALL 1-800-VIVITROL (1-800-848-4876), 9AM8PM (EST).

What is the fax number for Accredo home infusion?

The number for your doctor to fax a prescription to Accredo is 888-302-1028.