Radicava Benefit Investigation And Enrollment Form

Radicava Benefit Investigation And Enrollment Form - Start the process of checking your patient s health insurance coverage by completing a patient signed Benefit Investigation and Enrollment Form BIF You can provide information to eligible patients with commercial insurance by giving them the Out of Pocket Assistance Program Brochure for RADICAVA ORS and RADICAVA IV for Patients

Benefit Investigation and Enrollment Form PATIENT NAME Please Print AUTHORIZED REPRESENTATIVE Please Print BY Signature of authorized representative RELATIONSHIP TO PATIENT DATE

Radicava Benefit Investigation And Enrollment Form

Radicava Benefit Investigation And Enrollment Form

When you are considering starting a patient on RADICAVA ORS ® or RADICAVA ® IV, it is important to begin with the Benefit Investigation and Enrollment Form (BIF) as soon as possible, as it begins the investigation into your patient's insurance coverage. When completing the BIF, be sure to provide: Patient and your office information

Benefit Investigation and Enrollment Form for RADICAVA ORS and RADICAVA IV Download the Benefit Investigation and Enrollment Form BIF to prescribe RADICAVA ORS or RADICAVA IV and enroll patients in the JourneyMate Support Program DOWNLOAD HCP Portal User Guide

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This will happen after your doctor has prescribed RADICAVA ORS or RADICAVA IV and submitted a Benefit Investigation and Enrollment Form BIF which includes your signature to check your health insurance coverage An Insurance Access Specialist will

ALS Guides Forms Tools Resources RADICAVA edaravone

Key steps in the process include TREATMENT DECISION an appropriate treatment BENEFITS VERIFICATION Patient visits their doctor who determines whether RADICAVA is Before beginning treatment the patient s insurance coverage must be confirmed Doctor submits a Benefit Investigation and Enrollment Form to enroll the patient in the

ALS Treatment Insurance Information RADICAVA Edaravone

You and your doctor complete the Benefit Investigation and Enrollment Form and submit to Searchlight Support Searchlight Support contacts you to verify that you do not have health insurance coverage and to prequalify you based on your household size and income

ALS Care Locator Medical Practice Enrollment RADICAVA edaravone

2 Edaravone MCI 186 ALS 19 Study Group Safety and efficacy of edaravone in well defined patients with amyotrophic lateral sclerosis a randomised double blind placebo controlled trial

A JourneyMate Resource Specialist is ready to help you find information and educational resources about ALS and RADICAVA ® as you move forward on your journey with ALS. Call toll-free 1-833-788-1401 between 9 AM and 9 PM ET, Monday through Friday. Learn more and access helpful resources by visiting RadicavaORS.com.

Starting The Treatment Process RADICAVA Edaravone

Submitting a Benefit Investigation and Enrollment Form may help determine the cost of treatment Each infusion of RADICAVA lasts 60 minutes1 Initial infusion cycle 14 consecutive days on 14 consecutive days off1 Subsequent infusion cycles 10 days on within a 14 day period 14 days off1

Radicava Benefit Investigation And Enrollment Form

2 Edaravone MCI 186 ALS 19 Study Group Safety and efficacy of edaravone in well defined patients with amyotrophic lateral sclerosis a randomised double blind placebo controlled trial

Benefit Investigation and Enrollment Form PATIENT NAME Please Print AUTHORIZED REPRESENTATIVE Please Print BY Signature of authorized representative RELATIONSHIP TO PATIENT DATE

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