Fill Out Your Remistart Enrollment Form

1. What is the RemiStart Enrollment form used for?

The RemiStart Enrollment form is utilized for enrolling patients in the RemiStart® Patient Rebate Program for REMICADE®. This program offers financial assistance to individuals who have private or commercial health insurance that covers the costs of their REMICADE® medication. The form must be completed to receive rebates or checks for medication costs.

2. Who is eligible to enroll in the program?

Patients who are beginning or currently receiving treatment with REMICADE® and have private or commercial health insurance that contributes to their medication costs are eligible. However, individuals using government-subsidized healthcare programs, such as Medicare or Medicaid, cannot participate.

3. How do I submit the completed enrollment form?

You can submit the finalized enrollment form either by faxing it to 877-234-3048 or by mailing it to the address provided: Patient Rebate Program, 14001 Weston Parkway, Suite 103, Cary, NC 27513. Ensure that your form is signed correctly to facilitate processing.

4. What information is needed on the enrollment form?

The form requires personal information such as your name, gender, date of birth, contact details, and insurance information. You will also need to confirm your understanding and acceptance of the eligibility requirements and patient authorization regarding the use of your health information.

5. Can I receive both a rebate card and a check?

Yes, you can choose to receive your rebate for REMICADE® either on a MasterCard® Rebate Debit Card or via a check directly mailed to you or your infusion provider. This selection must be made on the enrollment form.

6. What happens if I change my insurance?

If your insurance information changes, it is your responsibility to inform the RemiStart program. Updating your information ensures you can continue receiving assistance without interruptions or issues with future rebate claims.

7. Can I opt out of the RemiStart program at any time?

Yes, participation in the program is voluntary, and you may withdraw at any time. To cancel your participation, notify AccessOne® by calling 888-ACCESS-1 (888-222-3771). Ensure you do this to avoid any further processing of your information.

8. How is my personal information used and protected?

Your personal information is used solely for the purposes of the RemiStart program, which includes assisting with your REMICADE® costs. While the company will take measures to protect your information, there is always a risk in sharing data. You have the right to see the information shared and may withdraw your consent to share said information with AccessOne® at any time.

Filling out the RemiStart Enrollment form can be a straightforward process, but common mistakes can lead to delays or problems with your application. One frequent error is forgetting to read the Patient Eligibility Requirements before starting the form. This critical step ensures that applicants fully understand the qualifications for the program, helping to avoid unnecessary complications later in the process.

Another common mistake occurs when providing personal information. Many people accidentally omit their date of birth, gender, or contact details. It is important to remember that this information must be complete for the program to assess eligibility properly. Leaving out any of these sections can lead to rejection of the application or delays in processing.

Additionally, individuals sometimes fail to select the appropriate enrollment option at the beginning of the form. There are specific sections for enrollment, updates, or information requests, and selecting the wrong option could send applicants on the wrong path, leading to further confusion.

An equally significant issue arises when individuals do not specify their insurance information completely. It is crucial to provide accurate details about private or commercial insurance, as this is a requirement for enrollment. Insufficient or incorrect insurance data might result in ineligibility for the rebate program.

Moreover, some applicants neglect to confirm whether they will seek reimbursement from state or federal healthcare programs. The form explicitly asks for this confirmation. A "No" answer is essential, as stipulating otherwise may disqualify an applicant from the program.

Submitting the form without reviewing it thoroughly is another mistake often made. Typos or unclear information can impede the processing of applications, leading to additional follow-up requests and delays. Taking a few moments to double-check each field is advisable to prevent these setbacks.

Furthermore, people sometimes overlook the requirement for a physician’s signature, which is necessary for program participation. Without this critical endorsement, applications may be deemed incomplete and subsequently rejected.

Marking the wrong method of receiving funds can also create issues. Applicants need to specify whether they prefer to receive the rebate via a debit card or check. Failing to make this selection can lead to complications in receiving the rebate.

In addition, individuals can forget to update their information if their insurance or contact details change. Many forget this important step after their initial enrollment. Notifying the program of changes ensures ongoing eligibility for the rebate.

Lastly, leaving blank fields in the signature section may lead to automatic rejection since all signatures must correspond to the patient’s acknowledgement of the information shared. Ensuring that every required area of the form is filled out correctly is vital for a smooth enrollment process.

The RemiStart Enrollment Form is an important document for patients looking to participate in the RemiStart Patient Rebate Program for REMICADE®. However, to navigate the enrollment process smoothly, several other forms and documents may also be required. Here’s a concise overview of those documents to assist in completing your enrollment.

• Patient Authorization Form: This form grants permission for healthcare providers to share your medical information with Janssen Biotech, Inc. It is essential for participation in the program.
• Proof of Insurance: This document includes a copy of your health insurance card. It demonstrates that you have private or commercial insurance that covers medication costs for REMICADE®.
• Explanation of Benefits (EOB): After each treatment, an EOB from your insurer shows the amount covered for REMICADE®. This is crucial for rebate requests under the program.
• Prescriber Information Form: This form provides details about your prescribing physician. It's required to ensure that your treatment is properly documented and managed.
• Infusion Provider Information: Document detailing where you will receive your REMICADE® infusions. This helps the program coordinate the rebates with your treatment facility.
• Privacy Policy Acknowledgment: A statement confirming that you’ve read and understood the privacy policy related to the use of your personal information in the program.
• Patient Eligibility Requirements: You must read this to ensure that you meet all guidelines necessary for enrollment in the rebate program.
• Medical History Form: Some programs may require a brief medical history to assess qualifications for the REMICADE® treatment.
• Financial Assistance Request: If applicable, this form may help you apply for additional financial support if your insurance provides insufficient coverage.
• Contact Information Update: A form to report any changes in your contact details or insurance coverage after enrollment.

Having these documents ready can streamline your enrollment in the RemiStart Patient Rebate Program, ensuring you receive the support needed for your REMICADE® treatment. For any questions, feel free to reach out directly to the program hotline or your healthcare provider.

The RemiStart Enrollment form shares similarities with several other documents commonly used in healthcare and insurance contexts. Below is a list outlining five such documents and their respective comparisons.

• Patient Registration Form: Like the RemiStart Enrollment form, the patient registration form collects essential personal and contact information, including the patient's name, address, and phone number. Both forms aim to facilitate the patient's access to necessary medical services or programs.
• Insurance Claim Form: This form is similar in its need for patient insurance details, such as policyholder information and coverage specifics. They both serve to initiate processes for reimbursement or assistance related to healthcare services.
• Medication Reimbursement Request Form: This document is closely aligned with the RemiStart Enrollment form, as it requires information about the patient's treatment and the prescribed medication. Each form functions to request financial assistance or reimbursement related to healthcare expenses.
• HIPAA Authorization Form: Both forms emphasize the importance of patient consent regarding the release of personal health information. The HIPAA authorization form details what information can be shared and with whom, paralleling the RemiStart form's requirement for patient consent related to data use.
• Patient Assistance Program Application: Similar to the RemiStart Enrollment form, this application assists patients in obtaining medications at reduced costs. Both documents screen for eligibility requirements and document patient insurance information while facilitating cost assistance programs.

When completing the RemiStart Enrollment form, consider the following important points:

• Do read the Patient Eligibility Requirements carefully before starting the form.
• Do provide accurate and complete personal and insurance information to avoid delays.
• Do confirm that you will not seek reimbursement from any government-subsidized healthcare programs.
• Do sign and date the form after reviewing all information provided.
• Do contact the provided number if you have any questions before submitting the form.

However, there are also some things to avoid:

• Don’t leave any required fields blank; incomplete forms could lead to processing issues.
• Don’t forget to provide your doctor’s information, as it is essential for the enrollment process.
• Don’t attempt to enroll if you are using state- or federal-subsidized healthcare programs.
• Don’t ignore any requests for additional information after submission; they are vital for your enrollment.
• Don’t neglect to notify the program if your insurance information changes after submitting the form.

Misconceptions about the RemiStart Enrollment form can lead to confusion or improper submission. Below are five common misconceptions:

• All patients are eligible to enroll in the RemiStart Program. Some patients may think they can enroll regardless of their insurance status. However, eligibility specifically requires private or commercial health insurance that covers a portion of REMICADE® costs.
• The RemiStart Program provides retroactive benefits. Many believe that the program can cover expenses incurred before enrollment. In reality, the offer is not retroactive, meaning it only applies to costs after enrollment.
• Patients can seek reimbursement from government programs and still enroll. Some might think they can enroll and also get reimbursement from Medicare, Medicaid, or other government-subsidized programs. The application clearly states that patients must confirm they will not seek such reimbursements to be eligible.
• Submitting the enrollment form guarantees a rebate. Individuals may assume that simply filling out and submitting the form will result in receiving a rebate. Rebate eligibility depends on meeting the program criteria, including submission of necessary documentation, such as Explanation of Benefits (EOB).
• Providing personal information is optional. Some might think sharing personal health information is not necessary for enrollment. However, the form requires permission to share health details with the program and its affiliates to process requests for assistance.

Understanding these points can help ensure that applicants complete the RemiStart Enrollment form correctly and without assumptions about the program.

When filling out the RemiStart Enrollment form, it’s important to keep several key points in mind to ensure a smooth process.

• Confirm Patient Eligibility: Before completing the enrollment form, first review the patient eligibility requirements. This step helps ensure you meet the criteria for the program.
• Provide Complete Information: Accurately fill out all sections of the form, including patient information, insurance details, and prescriber information. Incomplete forms may delay your enrollment.
• Choose Your Payment Option: You can opt to receive rebates via a MasterCard® Rebate Debit Card or request a check sent directly to you or your infusion provider. Make a clear selection on the form.
• Insurance Information is Crucial: Include specific details about your private or commercial insurance coverage. A copy of your insurance card may be beneficial for reference.
• Understand Reimbursement Restrictions: Confirm that you will not seek reimbursement for REMICADE® expenses from certain government-funded programs. This is a requirement to enroll in the Rebate Program.
• Submit Required Documentation: Ensure that an Explanation of Benefits (EOB) or pharmacy receipt is submitted after each infusion to process your rebate. Failure to do so may hinder your ability to receive rebates.
• Contact Information is Key: Provide a valid email address and phone number. This will allow the program to reach you for any updates or necessary communications regarding your enrollment.

Understanding these points can simplify your experience when using the RemiStart Enrollment form. You can reach out for assistance if any questions arise during the process.