Flexforward enrollment form 2025

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The FlexForward Enrollment Form is a document designed for patients seeking support services related to the ZILRETTA treatment for knee osteoarthritis. It collects patient and prescriber information, insurance details, diagnosis, clinical information, and prescription specifics. The form also includes sections for physician and patient authorization to share protected health information necessary for coordinating care and financial assistance.

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Click ‘Get Form’ to open the flexforward enrollment form in the editor.
Begin by filling out the Patient Information section. Enter the last name, first name, address, city, state, ZIP code, cell phone number, home phone number, email address, gender, date of birth, and SSN for insurance verification.
Proceed to the Prescriber Information section. Input the prescriber's last name, first name, NPI number, state license number, tax ID number, DEA number, office name and address along with contact details.
In the Insurance Information section, indicate if the patient is uninsured. If insured, provide details about primary and secondary insurance plans including plan names and IDs.
Complete the Diagnosis and Clinical Information section by selecting appropriate ICD-10 codes and injection-site locations. Note any previous treatments tried by the patient.
Fill out Prescription Information with details about ZILRETTA dosage and directions for use. Ensure compliance with state prescription laws.
Sign in the Physician Authorization section to confirm medical necessity and authorize Flexion Therapeutics to process information as needed.
Finally, complete the Patient Authorization section by providing necessary signatures and dates before submitting your form.

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Can I sign my flexforward enrollment form with my mobile phone?

Sure, it is possible with DocHub. This trustworthy and compliant online service has a phone-based signing option. Once you log in to your DocHub account and add your flexforward enrollment form to our editor, fill out all necessary areas and utilize the Sign feature on the top barf. Click on Create your signature and choose Phone from the available choices. Here, you scan a QR code with your smartphone and draw your signature on your phone screen, as you normally do when signing physical papers. If you access DocHub right from your mobile device, you can electronically sign your document by drawing your eSignature, uploading its picture, or simply with a typed name.

How do you fill out flexforward enrollment form online?

You may get and edit your flexforward enrollment form online by using DocHub. Its simple yet feature-rich design allows you to begin effective work right after you register your account. Create your account and add your file, and then our interface will guide you through our stress-free form completion experience.