Fillable Informaon and consent for the paent support program (Desjardins Insurace)

Fill Online, Printable, Fillable, Blank Informaon and consent for the paent support program (Desjardins Insurace) Form

Use Fill to complete blank online DESJARDINS INSURACE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Informaon and consent for the paent support program (Desjardins Insurace)

On average this form takes 11 minutes to complete

The Informaon and consent for the paent support program (Desjardins Insurace) form is 3 pages long and contains:

  • 0 signatures
  • 13 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Desjardins Insurace forms online.

BROWSE DESJARDINS INSURACE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Informaon and consent for the paent
support program for specialty drugs
16078E (2020-10)
INFORMATION
The prescripon drug that is the object of your request is part of our paent support program. Designed to help you
beer manage your medical condion, this program provides you with many benets such as access to professional
support from a team of pharmacists. For more informaon, see the Prior Authorizaon Drugs and the Paent Support
Program brochure, available at www.desjardinslifeinsurance.com/PAD.
If your contract includes the program, you may be required to parcipate.
A healthcare professional from the provider selected by Desjardins Insurance will contact you to let you know the
status of your request, to explain how the program works and to direct you to a preferred pharmacy. That professional
may also contact your aending physician to get any missing informaon. The informaon obtained as a result of this
prior authorizaon request will be sent to the third party and used to process your request. This is why your signature
is required.
IMPORTANT
As part of the paent support program, you will be reimbursed for your specialty drug only if you purchase it
through the preferred pharmacy network.
CONSENT TO DISCLOSE TO A THIRD PARTY
For the sole purpose of the paent support program, I authorize Desjardins Insurance to disclose to the third party
personal informaon about me, especially my medical informaon, that is needed for the program. I understand that
the third party may share this informaon with my doctors, pharmacists and other healthcare professionals as part
of this program.
This consent also applies to the disclosure of personal informaon concerning my dependents, insofar as this request
involves them.
Please ll out this page only if you live outside Quebec.
This consent is an integral part of the aached Prior Authorizaon Request form.
Desjardins Insurance life health rerement logo
Last name and rst name of the member (PLEASE PRINT) Contract No. Cercate No.
Email address of the member
Signature of the member Date
Last name and rst name of the parent or legal guardian (if necessary)
Signature of the parent or legal guardian (if necessary) Date
12552E (2020-09)





 











     
  
   
 
 
                  








 
  
  
  
   
   
 
  

No

  

PROGRAM






g

 

 
No


g
 
No

















 
 

PRINT
NEW REQUEST





 Yes 




  

OUTCOME








  

  



  
  









  
  
  
  
  
  
  



 BASFI
( 

    
  %


  
  




 Yes   Yes 
  
 



   



















•  









• 


Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Informaon and consent for the paent support program (Desjardins Insurace)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document