Spravato With Me Enrollment Form - Web once you and your doctor have decided that spravato® is right for you, enrolling into the spravato withme patient support program, including signing the patient authorization form, enables spravato withme to help you start on your prescribed medication as soon as possible by verifying your insurance benefits, confirming coverage and sharing. Find spravato® coverage, cost support, and educational resources. The form includes patient and prescriber information, insurance details, clinical information, and patient authorization. You can print, scan and upload a signed patient authorization form, choose to email patients the link to the patient authorization form for them to sign electronically, or have them sign electronically as you. Spravato withme cannot process this rebate form if you have not completed this process. Web by signing, dating, and submitting this form, you confirm that you already enrolled in the spravato withme savings program and you received your savings program card before receiving your spravato® medication. This form is intended only for use by outpatient medical ofices or clinics, excluding emergency departments. This section is to be completed by the prescriber. Web plus, learn how you could benefit from our patient support program (if you qualify), spravato withme, as well as access spravato® educational resources like informative faqs, our patient brochure and more. Web spravato withme patient enrollment and authorization.
You can print, scan and upload a signed patient authorization form, choose to email patients the link to the patient authorization form for them to sign electronically, or have them sign electronically as you. Web once you and your doctor have decided that spravato® is right for you, enrolling into the spravato withme patient support program, including signing the patient authorization form, enables spravato withme to help you start on your prescribed medication as soon as possible by verifying your insurance benefits, confirming coverage and sharing. This form is intended only for use by outpatient medical ofices or clinics, excluding emergency departments. Find spravato® coverage, cost support, and educational resources. This section is to be completed by the prescriber. Web spravato withme patient enrollment and authorization. Spravato withme cannot process this rebate form if you have not completed this process. Spravato withme is limited to education about spravato®, its administration, and/or the condition it treats. The form includes patient and prescriber information, insurance details, clinical information, and patient authorization. Web plus, learn how you could benefit from our patient support program (if you qualify), spravato withme, as well as access spravato® educational resources like informative faqs, our patient brochure and more. Web by signing, dating, and submitting this form, you confirm that you already enrolled in the spravato withme savings program and you received your savings program card before receiving your spravato® medication.