Patient Enrollment Authorization Form Patient Enrollment Authorization Form 2026

1. Click ‘Get Form’ to open the Patient Enrollment Authorization Form in the editor.
2. Begin by selecting your status regarding ViiV Healthcare medicines. Choose from options such as not taking a medicine yet, having a prescription, or currently taking a medicine.
3. Fill in your personal details including First Name, Last Name, Date of Birth, and contact information. Ensure all fields marked as required are completed.
4. Provide your health insurance information. If you do not have insurance, check the appropriate box and attach copies of your insurance cards if applicable.
5. Enter your doctor’s information including their name and contact details. Indicate whether you give permission for your health insurance coverage information to be shared with them.
6. Review the Patient Authorization and Release section carefully. Sign and date where indicated to allow ViiVConnect to access your health insurance information.
7. If applicable, provide caregiver information and signatures for patients under 18 years of age.

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