ENROLLMENT ASSISTANCE
Use this form as a guide for completing the enrollment form.
ENROLL NOW WITH
3 OPTIONS
Please review the 3 options below to access The Organon Access Program and choose the method that best works for you and your patient. If your patient is requesting a referral to the Organon Patient Assistance Program, be sure to include all information, including a prescription for RENFLEXIS. Please be sure all signatures are included prior to submitting forms to The Organon Access Program.
Option
1
Electronic Enrollment
via CoverMyMeds
Click to enroll
Allows providers to electronically enroll patients into
The Organon Access Program and initiate other access services.
With CoverMyMeds, you can:
- Perform benefits investigations and submit prior authorizations
- Access the Organon Co-pay Assistance Program
- Track patient case status
- Submit prescriptions
Option
2
Electronic Enrollment
via Docusign
FOR PATIENT IN OFFICE
2023 ELECTRONIC
ENROLLMENT FORM
FOR PATIENT NOT IN OFFICE
2023 ELECTRONIC
Health Care Provider
Enrollment form
These forms can be signed and submitted electronically via DocuSign.
Option 1
Electronic Enrollment
via CoverMyMeds
Click to enroll
Allows providers to electronically enroll patients into
The Organon Access Program and initiate other access services.
With CoverMyMeds, you can:
- Perform benefits investigations and submit prior authorizations
- Access the Organon Co-pay Assistance Program
- Track patient case status
- Submit prescriptions
Option 2
Electronic Enrollment
via Docusign
FOR PATIENT IN OFFICE
2023 ELECTRONIC
ENROLLMENT FORM
FOR PATIENT NOT IN OFFICE
2023 ELECTRONIC Health Care
Provider Enrollment form
These forms can be signed and submitted
electronically via DocuSign.
Option 3
Download, Print & Fax
DOWNLOAD THE 2023
ENROLLMENT FORM
Download this form to fill out, print, and fax.
ENROLLMENT ASSISTANCE
2023 SAMPLE
ENROLLMENT FORM
Use this form as a guide for completing the
enrollment form.