What if I miss a signature?

Missing signatures commonly delay processing. Return the form to the signer for a dated signature or use an approved electronic signature solution that preserves an audit trail and consent evidence.

Can I submit supporting documents later?

Some programs accept supplemental documents; however, delayed attachments can postpone eligibility determinations. Submit a complete packet when possible to avoid follow-up requests.

Is an electronic signature valid?

Electronic signatures are valid under ESIGN (15 U.S.C. ch. 96) and UETA in most states when intent, consent, attribution, and record retention are demonstrable.

How do I protect PHI during submission?

Use HIPAA-compliant transmission channels, limit data to the minimum necessary, and store records with AES-256 encryption at rest and TLS 1.2/1.3 in transit.

What if insurance information is incorrect?

Incorrect payer or member IDs will cause claim rejections. Confirm insurer name, member ID, and group number before submission to reduce denials.

Who to contact for program-specific questions?

Refer to AMAG Assist program materials for the designated contact. Program administrators can confirm submission destinations, required documents, and escalation steps.

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AMAG Assist Reimbursement Program Enrollment Form

AMAG Assist Reimbursement Program Enrollment Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

AMAG Assist™ Reimbursement Program – Enrollment Form

To enroll, please complete this form online and print it out OR print and complete by hand, then fax to AMAG Assist at 866-470-5871. If completing this form online you may not be able to save your changes, and may wish to retain a printed copy for your records. Should you have any questions, please call AMAG Assist at 877-411-2510 and select option 2 between the hours of 9 AM and 7 PM EST. Please note that the signed AMAG Assist Release Form must be received before services can be provided.

AMAG Assist offers claims tracking to monitor the status of your Feraheme™ (ferumoxytol) Injection For Intravenous (IV) use claims. This service confirms that claims are being processed appropriately by the payor. Would you like to enroll in this service? Yes No

Provider Information

Physician Name:

Facility Name:

Specialty:

Address:

City, State, ZIP:

Office Contact:

Phone: Fax:

Tax ID: NPI:

State License # (required for PAP):

Clinical Information

Patient Diagnosis:

Date of Diagnosis:

Is the patient currently on dialysis? Yes No

Is the patient currently on ESA therapy? Yes No

If yes, name of therapy:

Previous iron therapies:

Product Information

Drug:

Dosage:

Estimated Treatment Start Date:

Product Shipping Address* (if different from above):

Patient Information

Patient Name:

Patient SS#: DOB:

Address:

City, State, ZIP:

Phone:

Contact Name (if other than patient):

Contact Phone:

Patient Insurance Information

Medicare Eligible? Yes No Date:

Primary Insurance Company:

Insurance Phone Number:

Policy #: Group #:

Name of Insured:

Secondary Insurance Company:

Insurance Phone Number:

Policy #: Group #:

Name of Insured:

For insured patients: How will Feraheme be supplied?

Office Inventory Specialty Pharmacy

Patient Financial Information*

Annual Household Income:

Number Living in Household:

Items denoted by an asterisk (*) are required for Patient Assistance Program applications only.

Completion of the AMAG Assist Release Form is also required before services can be provided.

AMAG Assist™ – Release Form

Please fax the completed form to AMAG Assist at 866-470-5871. Should you have any questions, please call AMAG Assist at 877-411-2510 and select option 2 between the hours of 9 AM and 7 PM EST. Please note: this signed form must be received before services can be provided.

Patient Name: Patient DOB:

Patient Authorization

I authorize my insurance company, employer, hospital, physician, pharmacy, or any other health care provider or payor to share or disclose to AMAG Pharmaceuticals, Inc. and its vendors, representatives, or agents (collectively, “AMAG”) my relevant medical and financial information, including personal information, for the purpose of my participation in AMAG Assist.

I also authorize AMAG to use and disclose any such records and information to any necessary persons or entities for the purpose of my participation in AMAG Assist and the overall administration of the program. I understand that my information will be treated confidentially to the extent required by law. AMAG may use or disclose my information to refer me to, or to determine my eligibility for, other programs, foundations or alternate sources of funding or coverage that may be available to provide assistance to me with the costs of my Feraheme™ (ferumoxytol) Injection For Intravenous (IV) use or related treatments or therapies.

Except as may be required or permitted by law, I understand that any information that reveals my identity will not be used for any purpose other than for this program unless I give my written consent to AMAG. I verify that the information provided in this application is complete and accurate. I understand that AMAG reserves the right at any time and without notice to modify or discontinue AMAG Assist (including any assistance provided to me) and the related eligibility criteria. I certify that I am a resident of the United States. I have read, understand, and agree to all of the above.

Patient Signature:

Date:

Provider Authorization

I represent that the information contained in this application is complete and accurate to the best of my knowledge. I understand that AMAG Pharmaceuticals, Inc. reserves the right to modify or terminate the AMAG Assist program at any time and without notice. My signature certifies that Feraheme provided by AMAG Assist will not be resold or offered for sale, trade, or barter and will not be returned for credit. I understand that AMAG reserves the right to recall the product if necessary. I understand that I am under no obligation to prescribe any AMAG products to participate in AMAG Assist and that I have not received, nor will receive, any benefit from AMAG for prescribing an AMAG product. I understand that AMAG is not responsible for filing claims and that all final decisions on diagnosis, the need for treatment and the appropriateness of Feraheme for a particular patient rest with me as the patient’s provider. I agree to abide by this certification throughout my participation in AMAG Assist.

Print Provider Name:

Provider Signature:

Date:

What the AMAG Assist Reimbursement Program Enrollment Form Is

The AMAG Assist Reimbursement Program Enrollment Form collects patient, prescriber, and transaction data needed to evaluate eligibility for AMAG-sponsored financial assistance and to process reimbursement requests for eligible therapies. The form typically requires patient identifiers, insurance and payer details, prescriber contact and licensing data, medication and dosing information, proof of purchase or invoice, and a consent permitting release of medical records. Healthcare teams, pharmacies, and patient support coordinators use the completed form to initiate benefits investigation, submit documentation for reimbursement, and maintain records for audit and compliance purposes.

Why Completing This Enrollment Form Matters

Accurate completion authorizes AMAG Assist to verify benefits, pursue reimbursement, and determine patient assistance eligibility. Proper consent and complete supporting data reduce processing delays, lower the risk of denials, and help maintain HIPAA-compliant handling of protected health information.

Who Typically Completes and Signs the Form

Typical participants include the patient (or authorized caregiver), the prescribing clinician or clinic staff, and pharmacy or reimbursement support personnel.

Patients — enroll themselves or authorize a caregiver to provide information and sign on their behalf.
Prescribers and clinic staff — provide clinical details, NPI, and certify prescribed therapy information.
Pharmacies or benefits coordinators — attach proof of purchase, EOBs, and submission-ready documentation.

Confirm roles before signing to ensure the correct consent pathway and to meet HIPAA and program requirements.

Key Sections Found on a Professional Enrollment Form

A complete AMAG Assist Enrollment Form is structured to capture identity, clinical justification, insurance details, financial facts, consent to obtain records, and signature authorization for reimbursement processing.

Patient Identity

Full legal name, date of birth, contact information, and preferred method for program communications; used to match records and insurance data.

Insurance Details

Primary and secondary insurer names, member ID numbers, group numbers, and plan type so benefits can be verified and claims submitted correctly.

Prescribing Clinician

Provider name, practice address, phone, NPI and license number to support medical necessity and to enable prior authorization or appeal work.

Medication & Dosing

Drug name, strength, dosing schedule, and quantity dispensed to confirm eligible therapy and to calculate reimbursement or copay assistance.

Financial Information

Patient cost share, proof of payment or invoices, and EOBs to substantiate reimbursement requests and determine assistance levels.

Consent & Authorization

Explicit patient authorization to obtain medical records and share information with payers and AMAG Assist; required for HIPAA-compliant processing.

Required Data Elements to Provide

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

Insurance ID: Primary payer ID

Prescriber NPI: Ten-digit NPI

Medication: Drug name and strength

Proof of Purchase: Invoice or receipt

Step-by-Step: Completing the Enrollment Form

Follow these steps in order to prepare a submission that can be accepted and processed without follow-up.

01

Gather Documents: Collect ID, EOBs, invoices, and prescription details.
02

Complete Fields: Enter patient, prescriber, insurance, and medication data carefully.
03

Obtain Signatures: Get patient and prescriber signatures where required.
04

Submit Package: Send via program portal or other accepted channels.

Where and How to Submit the Completed Form

Submission routes vary by program materials; the form usually includes the preferred delivery options and contact points.

Program Portal: Upload securely through the AMAG Assist portal when available.
Secure Email: Send to the designated secure inbox per program instructions.
Mail: Mail a paper copy to the address shown on the form if permitted.
Fax (If Allowed): Transmit to the fax number listed only if explicitly accepted.

Configuring an Online Enrollment Workflow

If you digitize the form, configure authentication, notifications, and template fields to match program requirements.

Field	Configuration
Authentication Method	Email link, SMS code, or stronger ID verification
Signature Capture	Electronic signature field with date stamp
Conditional Fields	Show insurer-specific fields only when relevant
Notifications	Automatic alerts to patient and coordinator

Digital Submission and Integration Considerations

Use secure platforms that support PDF, DOCX, and audit trails, and that can integrate with EHR or CRM systems when required.

File Formats: PDF, Word DOCX supported
Integrations: Salesforce, NetSuite, Microsoft 365
Authentication: Email, SMS, or advanced verification

Verify the platform supports HIPAA-compliant handling, secure storage, and a complete audit trail before using for patient submissions.

Timelines and Processing Expectations

Processing times and deadlines depend on program workload and payer responses; check program materials for firm timelines.

Enrollment Submission Deadline:

No universal deadline; submit upon therapy initiation

Initial Verification Window:

Often within 7–30 business days depending on volume

Appeal Response Time:

Varies by payer and program; follow up promptly

Document Retention Notice:

Keep copies until claim resolution completes

Follow-up Reminders:

Set automated reminders at 14 and 30 days

Typical Submission Milestones and Stages

Track these milestones from form preparation through final reimbursement to manage expectations and follow-ups.

01

Form Prepared

All fields completed and documents attached.

02

Signed and Authorized

Patient and prescriber signatures obtained.

03

Submitted

Form sent via portal, secure email, or mail.

04

Claim Processed

Payer adjudicates and reimbursement is issued.

Common Mistakes That Cause Delays

Missing or mismatched patient identifiers that prevent payer matching and trigger requests for corrected documentation.
Incomplete prescriber information or missing NPI that halts clinical review and prior authorization steps.
Failure to attach proof of purchase, invoice, or EOB, which leads to denials or requests for additional evidence.
Unsigned forms or unsigned consent sections that create HIPAA or authorization compliance issues requiring re-signature.

Risks and Consequences of Incorrect Submissions

Delayed Reimbursement: Processing delays

Claim Denial: Denial by payer

Out-of-Pocket Costs: Patient liable temporarily

HIPAA Violation: Privacy breach risk

Administrative Burden: Extra follow-up required

Tax Implications: Reporting complexity

Practical Submission Scenarios

Two common use cases illustrate how completed enrollment forms move from intake to reimbursement processing.

Clinic-Led Submission

A clinic coordinator completes the form and collects an invoice

Coordinator attaches the EOB and proof of payment
The completed packet enabled a benefits investigation and reduced follow-up requests by clarifying insurer liability and streamlining prior authorization steps.

Patient-Directed Enrollment

A patient fills the form online and uploads receipts

Patient provides an image of the prescription label
Online submission with proper consent sped confirmation of eligibility, allowing targeted copay assistance while preserving an electronic audit trail.

Supporting Documents and Export Options

List of common attachments and recommended export formats for submission and long-term storage.

Proof of Purchase

Include invoices, receipts, or merchant statements showing date, amount, and items purchased to substantiate reimbursement claims.

Explanation of Benefits

Attach EOBs from insurers showing adjudication details, patient responsibility, and denial or copay amounts.

Prescription Documentation

Provide prescription labels or pharmacy dispensing records showing NDC, fill date, and quantity dispensed.

Export Formats

Save final package as PDF/A for archive and compatibility; keep editable DOCX or original files for internal updates.

eSignature Solution Pricing and Capability Comparison

Below is a concise comparison of entry pricing and select capabilities for signNow versus common competitors to consider when choosing an eSignature provider.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, submitting, and resolving issues with the AMAG Assist Enrollment Form.

Need help? Contact support

What if I miss a signature?
Missing signatures commonly delay processing. Return the form to the signer for a dated signature or use an approved electronic signature solution that preserves an audit trail and consent evidence.
Can I submit supporting documents later?
Some programs accept supplemental documents; however, delayed attachments can postpone eligibility determinations. Submit a complete packet when possible to avoid follow-up requests.
Is an electronic signature valid?
Electronic signatures are valid under ESIGN (15 U.S.C. ch. 96) and UETA in most states when intent, consent, attribution, and record retention are demonstrable.
How do I protect PHI during submission?
Use HIPAA-compliant transmission channels, limit data to the minimum necessary, and store records with AES-256 encryption at rest and TLS 1.2/1.3 in transit.
What if insurance information is incorrect?
Incorrect payer or member IDs will cause claim rejections. Confirm insurer name, member ID, and group number before submission to reduce denials.
Who to contact for program-specific questions?
Refer to AMAG Assist program materials for the designated contact. Program administrators can confirm submission destinations, required documents, and escalation steps.

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