Patient Enrollment Form Phone: 844-267-8678 Fax: 844-404-8876 www.clozapinerems.com Instructions for Prescribers For immediate enrollment, please go to www Get Big Discounts From Great Patent Companies. Request Info Today. PATIENT ENROLLMENT FORM Fax number: 1-866-363-6389 Phone number: 1-866-363-6379 Section 1 should be completed for insured patients. Section 2 should be completed for ZYDELIG® AccessConnect™ Patient Enrollment Form Fax enrollment form and copies of ALL patient medical and pharmacy insurance to ZYDELIG AccessConnect at 1-855 2016/2017 Patient Enrollment Form *Required *SELECT ONE: Patients must read this and sign the acknowledgment on the previous page before they can participate in MERCK PATIENT ASSISTANCE PROGRAM ENROLLMENT FORM PATIENT MUST COMPLETE THIS SIDE. Applicant Authorization for Use and Disclosure of Personal Health Information PATIENT ENROLLMENT FORM Please complete and fax this form to (877) 736-6506. For assistance or additional information, call (877) 744-5675, Monday-Friday, 8 am-8 Patient Enrollment Form for THIOLA® Total Care Hub Phone: 844?4?THIOLA (844?484?4652) Retain a copy of this form in the patient's records. ZYDELIG® AccessConnect™ Patient Enrollment Form Please complete and fax this form to 1-855-553-8672 For assistance or additional information, call 1-844-6ACCESS Enrolling with IWP is easy. Simply fill out the form below and our team will contact you today, so that you can begin receiving your workers' compensation or auto Once the form is signed, the patient's personal information might not be covered by any federal law about the use of the personal information or how it is disclosed. Once the form is signed, the patient's personal information might not be covered by any federal law about the use of the personal information or how it is disclosed. Patient Enrollment Form Please fax the completed form with a copy of the front and back of the patient's insurance card to 1-877-633-9522. *Patient First Name: Patient must sign and date the Patient Authorization and Notice of Release of Information on page 3 for this Patient Enrollment form to be Home Complete the Enrollment form (name, address, Patient enrollment in the Clozapine REMS Program is confirmed prior to dispensing clozapine
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