PATIENT ACCESS &SUPPORT SERVICES
PATIENT SELF-ENROLLMENT FORM
We've Got You.
Thank you for choosing CureConnect. This form helps us understand your situation so we can guide you
through insurance coverage, financial assistance, treatment access, and ongoing support.
1 PATIENT INFORMATION
Full Name:
Date of Birth (YYYY-MM-DD):
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Address:
Preferred Method of Contact:
Phone
Email
Text Message
YOUR HEALTHCARE PROVIDER
Family Doctor / Nurse Practitioner / Specialist Name:
Clinic Name (if known):
Phone Number (optional):
Format: (000) 000-0000.
3 HOW CAN WE HELP YOU?
What best describes your situation? (Please select all that apply)
I have been prescribed a medication and want to know if it is covered.
I am interested in a weight management medication.
My insurance has denied coverage.
I need help understanding my insurance benefits.
I want to explore financial assistance options.
I need help accessing my treatment.
I have been prescribed a specialty medication.
Other:
TREATMENT INFORMATION
If you know the name of the medication or treatment, please provide it:
EXAMPLES:
Ozempic®, Wegovy®, Mounjaro®, Zepbound®,
Dupixent®, Skyrizi®, Humira®, Stelara®,
Cosentyx®, or any other prescribed therapy.
SERVICES REQUESTED
COMPREHENSIVE ACCESS ASSESSMENT™ Insurance coverage investigation, eligibility assessment, financial assistance review, and personalized access report.
PRIOR AUTHORIZATION COMPLETION & SUBMISSION Available only when combined with another service package.
Insurance follow-up, pharmacy coordination, approval monitoring, and ongoing support .
Our most comprehensive option. Coverage investigation, eligibility assessment, prior authorization support, approval monitoring, pharmacy coordination, and ongoing follow-up.
All prices in CAD. Taxes may apply.
INSURANCE INFORMATION (OPTIONAL)
Do you currently have insurance coverage?
Yes
No
Not Sure
Insurance Company:
Group Number (optional):
Certificate Number (optional):
PATIENT CONSENT
I authorize CureConnect to contact me and collect, use, and disclose my personal information and personal health information as necessary to investigate insurance coverage, assess treatment eligibility, coordinate support services, communicate with insurers, pharmacies, laboratories, patient support programs, healthcare providers, and other organizations involved in my care. I understand that CureConnect provides patient navigation, coordination, administrative support, and access services. I understand that CureConnect does not provide medical advice and does not prescribe medications.
I consent to the collection and use of my information for the purposes described above.
Signature:
Date:
-
Month
-
Day
Year
Date
DISCLAIMER
CureConnect does not prescribe medications, provide medical advice, guarantee insurance coverage, or guarantee eligibility for any treatment, funding program, or patient support program. Coverage and eligibility decisions are determined by insurers, manufacturers, healthcare providers, and applicable program criteria.
SUBMIT YOUR ENROLLMENT
Email:
patient@cureconnect.ca
Phone:
506-612-2371
Fax:
506-571-0567
Website:
www.cureconnect.ca
We'll review your
information and contact
you within 1 business day.
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