Services Form Enrollment Instructions for 2025

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Services Form Enrollment Instructions for Preview on Page 1
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The document provides detailed enrollment instructions for the BENLYSTA medication, which is used for treating adult patients with active, autoantibody-positive systemic lupus erythematosus (SLE). It outlines the services offered by BENLYSTA Gateway, including benefits investigation, co-pay assistance, patient assistance for uninsured patients, specialty pharmacy triage, and prior authorization tracking. The document emphasizes the importance of completing and signing the Services Request Form for processing and includes sections for patient and provider information. Additionally, it contains important safety information regarding potential risks and side effects associated with BENLYSTA.
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What is the 855A? ❖ The Medicare Enrollment Application for Institutional Providers. ❖ This form is also used to submit changes to your enrollment data.
All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.
Enrollment forms are one of the most important tools for any organization. They provide you with the necessary information to get people signed up and ready for your services, whether theyre students, employees, or members.
Medicare Enrollment Application: Institutional Providers (CMS-855A): Institutional providers use this form to start the Medicare enrollment or revalidation process, or to change enrollment information.
What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.

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In the most basic terms, provider enrollment (sometimes referred to as payer enrollment) is the process through which healthcare providers apply to be included in a health insurance network. As an in-network provider, you will be able to treat patients who carry that insurance and be reimbursed for your services.

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Student Forms

Enrollment Services. In general, forms should be submitted to your home college. Submitting to another college may delay the processing of your request.

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Ways to enroll

To request a form, call 1-877-912-8880 (TTY: 1-866-565-8576). Mail your completed form to: Illinois Client Enrollment Services P.O. Box 1337. Chicago, IL

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CASE MANAGEMENT (CMCM) ENROLLMENT REQUEST

INSTRUCTIONS FOR CMCM AGENCY PROVIDERS: This form is used to enroll clients in your CMCM. Providers must fill the shaded areas of the form. CALL THE EMEDNY

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