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How to use or fill out Services Form Enrollment Instructions for BENLYSTA
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Click ‘Get Form’ to open it in the editor.
Begin by checking the appropriate boxes under 'SERVICES REQUESTED' to indicate which services you would like BENLYSTA Gateway to perform.
Fill out the 'PATIENT INFORMATION' section completely, ensuring to include your email address and a contact number for follow-up.
In the 'INSURANCE INFORMATION' section, attach legible copies of your insurance cards and provide details for both primary and secondary insurance.
Complete the 'PRESCRIBER, ACQUISITION, AND ADMINISTRATION INFORMATION' section by selecting how the medication will be acquired and providing necessary details.
If applicable, fill out the 'PATIENT ASSISTANCE PROGRAM (PAP) APPLICANTS' section to determine eligibility for assistance if uninsured.
Review all sections for accuracy, sign where required, and then fax both pages back to the provided number.
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Employee Enrollment Application / Change Request Form
Please complete this form in blue or black ink and submit to your employer when complete. Hours worked by employee per week. Date of hire (mm/dd/yyyy). LeftRead more
Fla. Admin. Code Ann. R. 12-28.003 - Enrollment Procedures
If unable to enroll using the Departments website, completing an Enrollment and Authorization for e-Services Program (Form DR-600, incorporated by reference inRead more
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