OTSUKA PATIENT EDUCATION LIAISON ENROLLMENT FORM 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'PATIENT INFORMATION' section. Enter your name, cell phone number, date of birth, sex, street address, preferred language, city, state, ZIP code, and email. Ensure all required fields are completed.
3. In the 'INSURANCE COVERAGE' section, indicate your insurance status by selecting one of the options: Commercial/private insurance, Medicare, Medicaid, or Uninsured.
4. Review the 'TELEPHONE COMMUNICATION & TEXT MESSAGES CONSENT' carefully. Check the boxes to consent to receive calls and/or texts from Otsuka America Pharmaceutical. Make sure you understand that consent is not a condition for program participation.
5. Sign and date the form in the 'PATIENT/LEGAL GUARDIAN SIGNATURE' section. If you are a legal guardian, please specify your relationship to the patient.
6. Complete the 'PATIENT AUTHORIZATION' section by reading through it thoroughly before signing. This authorizes Otsuka to share your protected health information as described.

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