V-Go Cares™ Support Program

I agree to the following:*
- By checking this box, "I, the undersigned, give my permission and authorization to my healthcare provider, their staff, and a Valeritas representative to (i) act on my behalf in speaking with V-Go Customer Care, (ii) enroll me into the V-Go Cares™ support program, which may include a 24-hour call back, (iii) share this information to permit benefit verification to take place on my behalf, and (iv) connect me with a third-party supplier who can provide me with a V-Go® wearable insulin delivery device and supplies."
*Required.
1. Patient Information
Name*
First Middle Last
Birth Date*
MM
DD
YYYY
Phone (cell)
One phone number is required.*
Phone (home)
Email
Street Address*
City*
State/Territory*
Zip*
2. Healthcare Provider Information
Name*
First Middle Last
Phone
Fax
City*
State/Territory*
Zip*
V-Go Customer Care may contact the office if additional information is needed or further action required.
3. Primary Insurance - Medical
Please provide accurate information to help expedite your request for support.
Primary Policy Holder's Name
First Middle Last
DOB
MM
DD
YYYY
Medical Insurance Name
Phone Number
Policy Number
Group Number
4. Primary Insurance - Pharmacy
Please provide accurate information to help expedite your request for support.
Pharmacy Insurance Name
Phone Number
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.}

V-Go Cares™ Support Program

1. Patient Information

2. Healthcare Provider Information

3. Primary Insurance - Medical

4. Primary Insurance - Pharmacy

5. Other Insurance Information

Important Risk Information