Where do I submit the completed form?

Submit the form through the channel specified by your clinic or program materials—this may be a secure portal, fax to a program number, or direct upload to the program case management system. Follow the instructions on the form for the preferred submission method to avoid misrouting.

Who must sign the form?

The patient or an authorized representative must sign the consent and authorization sections. If a caregiver or legal representative signs, attach documentation of authority such as a power of attorney or guardianship papers as required.

Can I sign electronically?

Electronic signatures are generally valid under federal ESIGN and applicable state laws when intent and consent are present. For some authenticated or notarized attestations, additional authentication or remote notarization may be required based on state rules.

How long does processing usually take?

Processing time varies by payer and program workload; typical benefits verification and PA initiation occur within 3–7 business days if all documentation is complete. Missing information will extend processing time and trigger follow-up requests.

What PHI disclosures are included?

The authorization specifies the types of PHI that may be shared with program staff, pharmacies, and payers for case management. Signing the form indicates consent to the listed disclosures and to communications consistent with that authorization.

How do I correct a mistake after submission?

Contact the program case manager or the submitting clinic immediately. Provide corrected fields and any supporting documentation; the program will update records and re-submit prior authorizations if permitted by the payer.

Electronic Signature
Templates
Education
Dupixent MyWay Program Enrollment Form

Dupixent MyWay Program Enrollment Form

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

DUPIXENT MyWay Enrollment Form

1 Patient Information

Patient Authorization

Name

DOB

Sex

M F

Address

City

State

Zip

E-mail

Preferred Language (if not English)

Preferred Phone

Alternate Phone

Best Hours to Call

Relationship to Patient (If signed by someone other than the patient, please describe your authority to sign on behalf of the patient.)

Voice Mail Message

Preferred Phone Alternate Phone No Message

Text Message

Preferred Phone Alternate Phone No Message

Patient Signature/Legal Representative

Date

2 Insurance

Please attach copies of front and back of primary and prescription cards.

No insurance

Primary Insurance

Rx Insurance (if different)

Insurance Phone

Rx Insurance Phone

Policy ID #

Group #

Policy Holder Name (First/Last)

Relationship to Patient

Rx Bin #

Rx PCN #

3 Prescriber

Prescriber Name

Site/Facility Name

Prescriber NPI #

Group Tax ID #

Address

City

State

Zip

Specialty

State License #

Office Contact

E-mail

Phone

Fax

4 Prescription

Rx DUPIXENT (dupilumab) 300 mg/2 mL Prefilled syringe 2-Pack

I have already sent this prescription to the specialty pharmacy above.

SIG

Qty

# of 2-packs

Maintenance Dose

Frequency

Qty

Refills

Known drug allergies

Preferred Specialty Pharmacy Name

Phone

Fax

Prescriber Signature

Date

5 Clinical

Patient Name

Prescriber Name NPI#

Diagnosis

Patient is 18 or over Patient has moderate to severe atopic dermatitis

Years since diagnosis

ICD-10 code

Current and Prior Therapies

Topical Therapies

Rationale

Systemic Corticosteroids, Immunosuppressants and/or Phototherapy

Rationale

Severity

Body Surface Area (BSA) involved

under 10% 10% or more

Sensitive areas affected (check all that apply)

hands feet face and neck genitals/groin scalp intertriginous areas other

6 Household Income

Required if enrolling in the DUPIXENT MyWay Patient Assistance Program

How many people live in your household?

Total annual household income

$0 to $100,000 Greater than $100,000

7 Patient Certifications

Text Messaging Consent

I have read and agree to the Text Messaging Consent

Patient Signature

Date

8 Patient Authorization to Use and Disclose Health Information

Patient Name

Prescriber Name NPI#

What the Dupixent MyWay Program Enrollment Form Is

The Dupixent MyWay Program Enrollment Form is a standardized patient support intake used to register eligible patients for the Dupixent MyWay patient support services. It collects patient identifiers, clinical and prescription details, insurance and pharmacy information, and authorization to share protected health information (PHI) with program staff. The form documents financial assistance eligibility, prior authorization support, and communications preferences. Correct completion ensures timely benefits investigation, prior authorization initiation, and coordination between prescriber, pharmacy, and support program teams while preserving required HIPAA protections.

Step-by-step: Fill and Submit the Dupixent MyWay Enrollment Form

Follow these steps to complete the form in order and avoid common processing delays.

01

Gather Documents: Collect ID, insurance card, and prescription details before you begin.
02

Enter Patient Data: Complete name, DOB, contact, and preferred pharmacy fields accurately.
03

Add Clinical Info: Provide diagnosis, relevant labs, and prescriber NPI or tax ID.
04

Sign and Send: Provide signature, date, and submit via the instructed channel.

Who Typically Completes This Enrollment Form

The form is completed by or on behalf of patients who are prescribed Dupixent and are seeking program services or benefits support.

Patients or authorized caregivers completing contact and consent details for support.
Prescribers or clinic staff supplying clinical diagnosis, NPI, and treatment plan information.
Specialty pharmacies and program case managers confirming insurance and processing authorizations.

Completion may involve the patient, prescribing clinician, specialty pharmacy, or a designated caregiver or case manager acting with patient authorization.

Essential Data Collected on the Enrollment Form

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY format

Insurance ID: Policy and group numbers

Prescriber Info: NPI and clinic details

Diagnosis: ICD code or description

Signature: Signed consent and date

Typical Submission Route for the Enrollment Form

The form follows a short routing sequence to verify eligibility, request prior authorization, and enable patient support services.

Prescriber Initiates: Prescriber or clinic uploads or completes the enrollment form.
Program Verification: Support staff review clinical and insurance data for eligibility.
Prior Authorization: Program assists with PA submission and payer follow-up.
Pharmacy Coordination: Specialty pharmacy receives final authorization and fills prescription.

Configuring an Online Workflow for the Enrollment Form

When completing the form electronically, configure authentication, conditional fields, and notifications to match clinical workflow needs.

Field	Configuration
Authentication	Email link or SMS code
Conditional Fields	Show insurance fields when 'insured' selected
Field Mapping	Map form fields to EHR or CRM
Notifications	Email confirmation to patient and prescriber

Technical and Integration Considerations for eSubmission

Confirm the platform supports secure PDF, audit trails, and HIPAA-compliant data handling before eSubmission.

Document Formats: PDF and DOCX supported
Integrations: EHR and CRM connectors available
RON Support: Remote notarization when required

Common Challenges That Cause Enrollment Delays

Incomplete insurance numbers or missing payer group codes lead to repeated requests and slower benefits verification from payers.
Mismatched patient name or DOB between enrollment form and insurer records can trigger identity verification and hold prior authorization processing.
Omitted prescriber NPI or missing signature prevents submission of a valid prior authorization and often results in denial.
Unsigned or undated patient authorization for PHI sharing will block program case management and coordination with pharmacies.

What a Professional Dupixent MyWay Enrollment Form Includes

A complete enrollment form groups patient identity, clinical facts, payer details, consent language, and signature blocks into structured sections for rapid review.

Patient Details

Clear fields for legal name, DOB, address, phone, and preferred contact method to ensure accurate communication and record matching.

Clinical Information

Prescriber name, NPI, diagnosis, relevant labs, and treatment history to support medical necessity and payer review.

Insurance Section

Primary and secondary payer entries, member ID, group number, and PCP information to expedite benefits investigation and copay support.

Financial Assistance

Eligibility questions for co-pay support, manufacturer assistance, or charitable programs and fields for household income where required.

Communications Consent

Explicit patient authorization for PHI disclosure, text/email preferences, and permitted representatives for program outreach.

Signature Block

Designated spaces for patient signature, date, and witness or prescriber attestation when required for program processing.

Comparing eSignature Pricing and Key Capabilities

Basic plan pricing and core capabilities vary by vendor; signNow is shown first for straightforward price and feature comparison without implying endorsement.

	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	Yes, 7-day trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Risks and Consequences of Incorrect or Incomplete Enrollment

Enrollment Delay: Delayed access

Coverage Denial: Claim or PA denial

HIPAA Violation: Potential compliance risk

Financial Loss: Missed assistance

Form Rejection: Resubmission required

Data Mismatch: Identity verification failure

Practical Tips to Avoid Delays and Ensure Valid Enrollment

Follow these best practices to reduce back-and-forth and improve processing speed for patient enrollment in program services.

Verify Patient Identity

Confirm full legal name and DOB match government ID and insurer records. Small mismatches commonly trigger identity verification and delay authorizations; correct this before submission.

Confirm Insurance Details

Copy payer name, member ID, and group number exactly from the insurance card. If the card shows multiple plan numbers, include all and indicate primary versus secondary coverage.

Include Complete Clinical Data

Provide diagnosis, treatment history, relevant lab results, and prescriber NPI. Insufficient clinical documentation is a leading cause of PA denials and repeated requests.

Use Secure eSubmission

Transmit the completed form using encrypted channels, include an audit trail, and retain signed copies to meet compliance and enable rapid follow-up.

Frequently Asked Questions About the Dupixent MyWay Program Enrollment Form

Answers to common questions about completion, signature, data privacy, and processing timelines for the enrollment form.

Need help? Contact support

Where do I submit the completed form?
Submit the form through the channel specified by your clinic or program materials—this may be a secure portal, fax to a program number, or direct upload to the program case management system. Follow the instructions on the form for the preferred submission method to avoid misrouting.
Who must sign the form?
The patient or an authorized representative must sign the consent and authorization sections. If a caregiver or legal representative signs, attach documentation of authority such as a power of attorney or guardianship papers as required.
Can I sign electronically?
Electronic signatures are generally valid under federal ESIGN and applicable state laws when intent and consent are present. For some authenticated or notarized attestations, additional authentication or remote notarization may be required based on state rules.
How long does processing usually take?
Processing time varies by payer and program workload; typical benefits verification and PA initiation occur within 3–7 business days if all documentation is complete. Missing information will extend processing time and trigger follow-up requests.
What PHI disclosures are included?
The authorization specifies the types of PHI that may be shared with program staff, pharmacies, and payers for case management. Signing the form indicates consent to the listed disclosures and to communications consistent with that authorization.
How do I correct a mistake after submission?
Contact the program case manager or the submitting clinic immediately. Provide corrected fields and any supporting documentation; the program will update records and re-submit prior authorizations if permitted by the payer.

Explore Templates

Louisiana Divorce Property Division Revocable Living Trust Revocable Living Trust Revocable Living Trust New Client Information Form Mortgage Purchase Agreement

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now