ARISTADA INITIO and ARISTADA Patient Enrollment Form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, gender, and contact details including cell and home phone numbers.
3. Provide insurance information. Fill in the insurance name, policyholder's name, member ID, and other relevant details. Ensure that this is pharmacy insurance information.
4. In the 'Prescriber Information' section, enter the prescriber's name and contact details. Include their NPI number and primary specialty.
5. Complete the 'Prescription Information' section by specifying the drug (EVZIO), quantity, directions for use (Sig), and delivery options.
6. Sign in the 'Provider Attestation' area to verify that all provided information is accurate. Remember that stamped signatures are not acceptable.
7. Finally, review all sections for completeness before submitting your form through our platform.

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