Benefits Investigation Form

By checking this box, "I give my permission and authorization to my healthcare provider, their staff and Valeritas Representative to (i) act on my behalf in speaking with V-Go Customer Care, (ii) enroll me into the support program with follow-up opt in for a 24-hour call back, (iii) connect me with a third-party supplier who can provide me with a V-Go wearable insulin delivery device and supplies, and (iv) share the following information to permit benefit investigation to take place on my behalf."

This submission confirms authorization of benefit investigation and global opt-in to V-Go Customer Care

*Required fields to be completed

1. PATIENT INFORMATION:

Patient Name (first, middle, last)*

Phone Number*

DOB*

To expedite your benefit research investigation and provide you with results, please complete as much of the requested information below before submitting

Address1*

Address2 (optional)

City*

State/Terrority* Zip*

Language

Pharmacy Name

Pharmacy Phone Number

Pharmacy Address1

Pharmacy Address2 (optional)

City

State/Terrority Zip

Caregiver Name (optional) (first, last)

Caregiver Relationship (optional)

Caregiver Phone Number (optional)

2. HEALTHCARE PROVIDER INFORMATION:

HCP Name (first, last)*

HCP Title

HCP Address1

HCP Address2 (optional)

City

State/Terrority

Zip*

Phone Number

Fax Number

Contact HCP Office with Benefit Result

Staff Contact Name (first, last)

3. PRIMARY INSURANCE - MEDICAL:

Primary Policy Holder's Name (first, last)

DOB

Medical Insurance Name

Phone Number

Policy Number

Group Number

4. PRIMARY INSURANCE - PHARMACY:

Pharmacy Insurance Name

Phone Number

Rx ID

Rx BIN

Rx GRP

Rx PCN

5. Other Insurance Information (Optional)

While we cannot guarantee your insurance company will pay for V-Go supplies, we will call them on your behalf to understand if you can fill your prescription at the pharmacy or through other stores as designated by your medical insurance. Please remember that Valeritas respects your privacy and will not share, rent or sell your personal information except as authorized by you. By signing, you appoint Valeritas as your agent for the purposes of (i) gathering medical and insurance coverage information on your behalf, (ii) following up directly with your insurer to find out if the V-Go is being reimbursed, (iii) what steps you’ll need to take to fill your prescription, and (iv) other purposes described above. You may be contacted if further details are needed.