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 gender. 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 insurance cards as required.
4. Complete the 'Diagnosis and Treatment' section by entering the patient diagnosis and prescribed dosing regimen for DALVANCE®. Include details for both first and second doses if applicable.
5. Fill in the 'Physician Information' section with the prescriber’s details including name, practice/facility name, contact information, and specialty.
6. If applying for the Patient Assistance Program (PAP), complete page 2 by providing household income and family member count. Ensure to sign where indicated.
7. Review all entries for accuracy before signing at the bottom of each page. Once completed, fax the form to 1-855-888-7206 as instructed.

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