Connects enrollment form 2026

1. Click ‘Get Form’ to open the connects enrollment form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, address, date of birth, primary phone number, email, and alternate contact name. Ensure all fields are completed accurately.
3. In the 'Insurance Information' section, provide details for both primary and secondary insurance. Attach a copy of the front and back of the insurance card(s) as required.
4. Complete the 'Diagnosis and Treatment' section by entering the patient diagnosis including code and prescribed dosing regimen for DALVANCE®. Specify details for both first and second doses.
5. Fill in 'Physician Information' with prescriber’s details including name, practice/facility name, specialty, contact information, and tax IDs.
6. Indicate your interest in acquiring medication through a specialty pharmacy if applicable. Provide any preferred pharmacies.
7. Finally, ensure that the physician declaration is signed by entering their signature, printed name, and date before submitting.

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