Can patients sign the enrollment form electronically?

Yes. Electronic signatures are generally valid under the federal ESIGN Act and state UETA laws. For healthcare forms carrying PHI, ensure the electronic process includes a consent disclosure and appropriate authentication.

Is a HIPAA Business Associate Agreement required?

If a third-party vendor will handle protected health information on behalf of a covered entity, a HIPAA Business Associate Agreement (BAA) is required to document responsibilities for PHI safeguarding.

Who may sign for a minor or incapacitated patient?

A parent or legal guardian typically signs for minors. For incapacitated adults, a court-appointed guardian or duly authorized representative with documented authority may sign; maintain evidence of authority in the record.

How do I correct an error after the form is signed?

Add a signed amendment or corrected form and retain the original with a note explaining the correction. Avoid editing a signed record; instead, create a new record that references the correction.

What steps protect the form during transmission and storage?

Use encryption in transit and at rest, role-based access controls, and tamper-evident signed PDFs with an audit trail. Limit access to staff with a documented need to know.

How can an enrollment be revoked or cancelled?

An enrolled patient or authorized representative may withdraw consent in writing; document the revocation, its effective date, and any consequences for ongoing services or billing.

Electronic Signature
Templates
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Patient Enrollment Form

Patient Enrollment Form

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

PATIENT ENROLLMENT

FAX COMPLETED FORM TO: 1-877-329-8484 PLEASE COMPLETE ALL FIELDS TO AVOID PROCESSING DELAYS

TOUCHPOINTS PHONE: 1-800-848-4876 TP ID# (TOUCHPOINTS USE ONLY):

INJECTION PROVIDER INFORMATION

Will your office/facility be injecting VIVITROL?

Yes, ALL doses

No, please locate an Injection Provider or refer to Provider below

Provider Name

Provider Address

Provider Phone #

Preferred specialty pharmacy (if applicable)

Special shipping instructions/restrictions

PATIENT INSURANCE INFORMATION

Payment Method Insured Paying out-of-pocket

ATTACH A COPY OF BOTH SIDES OF THE PATIENT'S INSURANCE CARD(S). IF NOT AVAILABLE, COMPLETE SECTION BELOW.

PRIMARY INSURANCE

Insurance Type HMO PPO Medicaid Medicare

Carrier Name

Policyholder Name

Relationship to Patient

Carrier Phone #

Policyholder Employer Name

Policy #

Group ID #

PHARMACY BENEFIT PLAN (PBM)

PBM Name

Policyholder Name

Relationship to Patient

PBM Phone #

Policyholder Employer Name

Policy #

Group ID #

Rx BIN #

PATIENT INFORMATION

Name (First) (Last)

Date of Birth

Gender
Male Female

Address

City

State

Zip Code

Home Phone #

Mobile Phone #

Best Day to Call M T W TH F

Best Time to Call Morning Afternoon Evening

Email Address

PATIENT DIAGNOSIS

Please check all that apply

Alcohol Dependence Opioid Dependence

303.00 303.91 304.00 304.03 304.72

303.01 303.92 304.01 304.70 304.73

303.90 303.93 304.02 304.71 Other

Patient has tried and failed the following medication(s):

Please list any known allergies to medications or other substances:

PRESCRIPTION INFORMATION

Patient Name

Date

VIVITROL 380 mg x 1 unit Inject 380 mg IM q4 weeks or q1 month Provider State License #

Refill times

Preferred specialty pharmacy (if applicable)

Special shipping instructions/restrictions

PRESCRIBER INFORMATION

Prescriber Name*

Prescriber Tax ID #

DEA #

State License #

NPI #

Prescriber Phone #

Fax #

Facility Name

Address

City

State

Zip Code

Staff Contact Name

Staff Contact Phone #

Staff Contact E-mail

PATIENT REPRESENTATIVE

By signing below, I authorize my Designee(s), listed below, to receive administrative information related to my treatment, such as appointment reminders, and to make decisions on my behalf.

Designee Name (1)

Relationship

Phone #

Designee Name (2)

Relationship

Phone #

Patient's Signature

Date of Signature

PATIENT AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

By signing below, I authorize the listed providers and entities to use and disclose information as described in this authorization.

Patient's Signature

Date of Signature

Parent/Guardian/Legal Representative’s Signature

Authority/Relationship to Patient

(Check if "yes") I would like to receive co-payment assistance from Alkermes.

INJECTION PROVIDER SELECTION INFORMATION

If you have requested injection services, Touchpoints will provide a selection of several injectors based on geographic proximity to the patient's address.

These options will be provided for the patient, and the selected injection services provider will be contacted to help coordinate services.

DIAGNOSIS CODE DESCRIPTIONS

Alcohol Dependence

303.00 Acute alcoholic intoxication, unspecified drunkenness

303.01 Acute alcoholic intoxication, continuous drunkenness

303.90 Other and unspecified alcohol dependence, unspecified drunkenness

303.91 Other and unspecified alcohol dependence, continuous drunkenness

303.92 Other and unspecified alcohol dependence, episodic drunkenness

303.93 Other and unspecified alcohol dependence, in remission

Opioid Dependence

304.00 Opioid type dependence, unspecified abuse

304.01 Opioid type dependence, continuous abuse

304.02 Opioid type dependence, episodic abuse

304.03 Opioid type dependence, in remission

304.70 Combinations of opioid type drug with any other drug dependence, unspecified abuse

304.71 Combinations of opioid type drug with any other drug dependence, continuous abuse

304.72 Combinations of opioid type drug with any other drug dependence, episodic abuse

304.73 Combinations of opioid type drug with any other drug dependence, in remission

NETWORK SPECIALTY PHARMACIES

Accredo Health Group, Inc.; Acro Pharmaceutical Services; Aetna Specialty Pharmacy®; Avanti Health Care; Avella Inc.; BriovaRx™; CareSite Pharmacy; CarePlus Pharmacy; Chartwell Pennsylvania, LP; Cigna; Commcare Pharmacy; Coram LLC; Costco Health Solutions; CuraScript, Inc.; CVS Caremark; Diplomat Pharmacy; Pharmacy Solutions; Fairview Health Services; Humana; Kelley-Ross & Associates Inc.; The Kroger Company; LDI; LegacyRx™; Lovelace Health System; Magellan Health Services, Inc.; Medicine Shoppe International, Inc.; MedVantx Inc.; OptumRx, Inc.; Orchard Pharmaceutical Services; Orsini Healthcare; Pharmacy Advantage; Prime Therapeutics LLC; Providence Health & Services; Reliance Rx; Reliant Healthcare; Restore RX. inc.; Transition Pharmacy Services; US Specialty Care®; Vital Care Rx; Walgreen Co.

IMPORTANT SAFETY INFORMATION FOR VIVITROL® (naltrexone for extended-release injectable suspension)

INDICATIONS

VIVITROL is indicated for treatment of alcohol dependence in patients able to abstain from alcohol in an outpatient setting; prevention of relapse to opioid dependence following opioid detoxification; and as part of a comprehensive management program including psychosocial support.

CONTRAINDICATIONS

Receiving opioid analgesics; current physiologic opioid dependence; acute opioid withdrawal; positive opioid screen or failed naloxone challenge; hypersensitivity to components.

WARNINGS/PRECAUTIONS

Vulnerability to opioid overdose; injection site reactions; precipitation of opioid withdrawal; hepatotoxicity; depression and suicidality; pain management considerations; eosinophilic pneumonia; hypersensitivity reactions; intramuscular injection cautions.

ADVERSE REACTIONS

Serious adverse reactions may include injection site reactions, eosinophilic pneumonia, serious allergic reactions, precipitation of opioid withdrawal, accidental opioid overdose, and depression/suicidality.

What the Patient Enrollment Form Is and When it’s Used

A Patient Enrollment Form collects identifying and administrative data to register an individual for clinical services, care programs, or membership-based health plans. Typical fields cover patient name, contact details, insurance information, emergency contact, primary care provider, consent acknowledgements, and demographic data. In the United States the form may be executed on paper or electronically subject to ESIGN and UETA rules; healthcare organizations should also evaluate HIPAA when the form will carry protected health information. Electronic workflows often pair the enrollment form with identity verification, consent disclosures, and secure storage.

Why a Clear Patient Enrollment Form Matters

A well-structured Patient Enrollment Form reduces intake errors, speeds eligibility checks, and documents consent. Accurate enrollment supports billing, care continuity, regulatory compliance, and auditability while helping organizations meet HIPAA privacy rules when PHI is collected.

Who Completes and Uses the Patient Enrollment Form

Intake staff, patients, authorized representatives, and third-party administrators commonly complete enrollment forms depending on the care setting.

Patients and guardians completing personal and medical-history fields at intake or online prior to first appointment.
Clinic or hospital administrative staff verifying insurance, eligibility, and consent for treatment or data use.
Case managers and program coordinators enrolling participants in care management, specialty clinics, or subscription services.

Role-based completion and clear signer identification reduce later disputes over consent, insurance coverage, and responsibility for fees.

Essential Sections Every Professional Patient Enrollment Form Should Include

A comprehensive form groups information to minimize duplicate entry, support verification, and capture legally required acknowledgements for treatment and data sharing.

Patient Details

Full legal name, date of birth, gender, preferred name, and government ID when required for identity verification and insurance matching.

Contact Information

Street address, city, state, ZIP, primary phone, alternate phone, and email to enable appointment reminders and secure communications.

Insurance Data

Payer name, member ID, group number, policyholder name and relationship, and effective dates to streamline eligibility and claim submission.

Emergency Contact

Name, relationship, and phone number for notification and care coordination when immediate family or a designated contact is needed.

Consent & Authorizations

Treatment consent, privacy notice acknowledgement, and specific releases for information sharing or payment — signed and dated by the appropriate party.

Clinical Baseline

Basic health questions or screening items relevant to intake; use checkboxes and standard response options to reduce transcription errors.

Step-by-Step: Completing a Patient Enrollment Form

Follow an ordered intake process to reduce errors and collect required consents before services begin.

01

1. Gather Documents: Collect ID and insurance card images for verification.
02

2. Enter Data: Complete fields carefully using exact spelling and formats.
03

3. Confirm Eligibility: Verify coverage dates and copay details with the payer.
04

4. Obtain Signatures: Secure patient or authorized representative signature and date.

How Electronic Enrollment Typically Works

Electronic enrollment follows a short workflow from document preparation through signature capture and final storage.

Prepare Form: Upload or create the enrollment form with required fields and conditional sections.
Send to Signer: Deliver via secure link, email invite, or in-clinic tablet for completion.
Authenticate: Apply appropriate signer authentication (email, SMS code, or stronger methods) as needed.
Store Record: Save signed document and audit trail to compliant storage for retention and retrieval.

Typical Digital Workflow Settings for Patient Enrollment

Common configuration options help balance user convenience with compliance and auditability.

Field	Configuration
Authentication	Email link, SMS code, or two-factor for sensitive PHI
Conditional Fields	Show insurance section only if patient indicates coverage
Audit Trail	Capture IP, timestamp, and client device metadata
Retention	Automatic archive to secure storage after signature

Technical and Integration Considerations for eSubmission

Ensure the platform supports required document formats and integrations for your intake systems.

Formats: PDF, DOCX, HTML are commonly supported
Integrations: Connectors for EHRs and CRM systems reduce manual entry
Authentication: Support for SMS, email, and advanced signer ID tools

Verify that the selected platform can export a tamper-evident PDF, produce an audit trail, and integrate with your recordkeeping systems.

Timelines and Processing Expectations

Processing time varies by organization size, payer response times, and whether identity verification is required.

Initial Intake Turnaround:

Same day to 3 business days for manual verification

Insurance Eligibility Check:

Immediate to 48 hours depending on payer response

Verification Escalation:

Allow 5–10 business days for manual appeals or corrected data

Electronic Signing:

Typically completed within 24–72 hours of invite

Record Availability:

Signed copy and audit trail available immediately post-signature

Key Enrollment Milestones

Track milestones from intake through active enrollment to ensure coverage and consent are documented.

01

Milestone 1 — Intake Submission

Patient completes form and returns it to intake staff.

02

Milestone 2 — Identity Verification

Staff confirms identity and matches insurance details.

03

Milestone 3 — Insurance Validation

Payer confirms eligibility or requests additional information.

04

Milestone 4 — Final Enrollment

Consent captured, file stored, and access provisioned.

Common Pitfalls That Delay Enrollment

Incomplete or misspelled names that prevent insurance matching and lead to claim denials or duplicate records.
Missing or expired insurance information that requires manual follow-up and slows authorizations for services.
Unsigned consent or absent authorized representative signatures for minors or incapacitated patients, invalidating enrollment.
Using inconsistent date formats or abbreviations that create data-entry errors and complicate automated processing.

Sensitive Data Elements to Protect

Full Name: Direct identifier

Date of Birth: Identity data

Insurance ID: Payment and eligibility data

Medical History: Protected health information

Contact Details: Used for notifications

Signature: Legal consent evidence

Risks and Potential Consequences of Errors

Claim Denials: Lost reimbursement

HIPAA Violations: Civil penalties and corrective actions

Fraud Allegations: Legal exposure and investigations

Delayed Care: Medical treatment postponement

Record Rejection: Enrollment not accepted

Audit Findings: Operational remediation required

Comparing eSignature Pricing and Core Capabilities

Basic pricing and feature distinctions for common eSignature vendors. signNow appears first; verify plan details with each vendor before purchase.

	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 free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About Patient Enrollment Forms

Answers to common queries about electronic completion, signer authority, data protection, and record updates for Patient Enrollment Forms.

Need help? Contact support

Can patients sign the enrollment form electronically?
Yes. Electronic signatures are generally valid under the federal ESIGN Act and state UETA laws. For healthcare forms carrying PHI, ensure the electronic process includes a consent disclosure and appropriate authentication.
Is a HIPAA Business Associate Agreement required?
If a third-party vendor will handle protected health information on behalf of a covered entity, a HIPAA Business Associate Agreement (BAA) is required to document responsibilities for PHI safeguarding.
Who may sign for a minor or incapacitated patient?
A parent or legal guardian typically signs for minors. For incapacitated adults, a court-appointed guardian or duly authorized representative with documented authority may sign; maintain evidence of authority in the record.
How do I correct an error after the form is signed?
Add a signed amendment or corrected form and retain the original with a note explaining the correction. Avoid editing a signed record; instead, create a new record that references the correction.
What steps protect the form during transmission and storage?
Use encryption in transit and at rest, role-based access controls, and tamper-evident signed PDFs with an audit trail. Limit access to staff with a documented need to know.
How can an enrollment be revoked or cancelled?
An enrolled patient or authorized representative may withdraw consent in writing; document the revocation, its effective date, and any consequences for ongoing services or billing.

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