Enrollment Forms

Specialty Pharmacy Enrollment Forms

Our interactive enrollment forms make sending prescriptions easy. Simply download the fillable form, type or print the appropriate information and return to WellDyne Specialty Pharmacy via fax – (800) 530 8589.

Once we receive the completed disease-specific enrollment form, WellDyne Specialty Pharmacy will:

  • Verify and coordinate insurance coverage
  • Provide prior authorization and financial assistance
  • A Patient Care Advocate will be assigned to the patient to coordinate medication delivery and assist with questions and medication compliance