Viivconnect enrollment form 2026

1. Click ‘Get Form’ to open the viivconnect enrollment form in the editor.
2. Begin by checking the services requested. Select all that apply, such as Benefit Verification or Co-pay Program.
3. Fill in the required fields under 'VIIV HEALTHCARE MEDICATION PRESCRIBED'. Enter the product name and dosage.
4. Complete the 'APPLICANT INFORMATION' section. Provide your full name, preferred phone number, date of birth, gender, address, household details, and Social Security Number if applicable.
5. If necessary, complete the 'SHIPPING ADDRESS' section for medicine delivery.
6. In 'ALLERGY AND HEALTH INFORMATION', list any known drug allergies and health conditions. Check the box if none apply.
7. Answer questions regarding prescription coverage accurately in the 'PRESCRIPTION COVERAGE' section.
8. Provide insurance information by filling out all relevant fields under 'INSURANCE INFORMATION'.
9. Complete the 'PRESCRIBER INFORMATION' section with your prescriber's details.
10. Finally, review and sign the 'PATIENT AUTHORIZATION AND RELEASE' section before submitting your completed form.

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