[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-194604-105":53,"doc-detail-194604-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","patient-authorization-and-enrollment-consents-co-pay-plus-and-ongoing-support","Patient Authorization and Enrollment Consents - Co-Pay Plus and Ongoing Support","","Provide a structured enrollment and authorization worksheet for a patient seeking Cosentyx support through Co-Pay Plus and ongoing patient support. Includes fields for patient demographics, patient/authorized representative signature and date, insurance/payer details, patient name and prescriber information, and product selection with adult or pediatric dosing schedules over a 28-day period. Captures consent to receive recurring marketing calls and texts, plus access preferences for ongoing support resources and reminders.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-authorization-and-enrollment-consents-co-pay-plus-and-ongoing-support/194604/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-authorization-and-enrollment-consents-co-pay-plus-and-ongoing-support/194604.png","ImageObject",442,249,{"name":88,"@type":89},"Melati","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who needs to sign the Patient Authorization and enrollment consents?","Question",{"text":109,"@type":110},"The form includes a checkbox for signing by the patient or an authorized representative, with signature and a date (MM/DD/YYYY).","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What consent does the form request for ongoing support?",{"text":114,"@type":110},"By checking the box, it agrees to receive recurring marketing calls and texts on behalf of Novartis Patient Support, including possible automatic or pre-recorded communications, with opt-out options.",{"name":116,"@type":107,"acceptedAnswer":117},"What product and dosing schedule details are captured in the enrollment form?",{"text":118,"@type":110},"It records Cosentyx product type and dose for adult and pediatric options, including loading and maintenance instructions over Weeks 0–4 and then every 4 weeks thereafter, plus pediatric dosing based on weight and 28-day quantity/refills.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},194604,1788440654,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":73},962085570644,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","|  First Name |  LastName\u003Cbr> Sex for Clinical Use:  | \u003Cbr> Male  | \u003Cbr> Female |\n| --- | --- | --- | --- |\n|  Dateof Birth (MM/DD/YYYY) |  |  |  |\n|  Address (NoPO Box) |  |  |  |\n\n\n| 2. Patient Authorization and Additional Enrollment Consents I have read andagreetothe Patient Authorization on page 4. X   Check here if signed by an  Patient/Authorized Representative Signature  Date (MM/DD/YYYY) Authorized Representative. |  |\n| --- | --- |\n| CO-PAY PLUS‡ FOR COSENTYX\u003Cbr>Pay as little as $0\u003Cbr> I have read and agree totheCo-Pay Plus Terms and Conditions on page 4. | GET ACCESS TO ONGOING SUPPORT\u003Cbr> I'd like to sign up for access to ongoing support. I’ll get COSENTYX tips, resources, and reminders from Novartis Patient Support atthe mobile phone number(s) Igave above.†\u003Cbr>†By checking this box, I agree to receive recurring marketing calls and texts from and on behalf of Novartis Pharmaceuticals Corporation. These calls and texts may be automatic or recorded in advance. The number of calls and message frequency varies. My consent is nota condition of getting any goods or services from Novartis. I can opt out of the program at anytime by calling 844-267-3689. I can also text\"STOP\"to any Novartis Patient Support Ongoing Support message toopt out of texts or\"HELP\"for more information about this service. Message and data rates may apply. |\n\n\n| Insurance/Payer | Plan Name | Policy Phone Number |\n| --- | --- | --- |\n| Member ID Number | RxGroup Number |  |\n| PCN Number | BIN Number |  |\n\n\n| Insurance/Payer | Plan Name | Policy Phone Number |\n| --- | --- | --- |\n| Member ID Number | Group Number |  |\n\n|  Patient Name\u003Cbr>4. Prescriber Information |  |  |\n| --- | --- | --- |\n|  First Name |  LastName |  |\n|  Address |  |  |\n|  City |  State | ZIP |\n|  Prescriber NPI Number |  |  |\n\n\n|  DateofBirth (MM/DD/YYYY) |\n| --- |\n|  Practice Name |\n|  Practice Phone Number |\n| Practice Contact Name |\n\n| Product Information (Adult) |  |  |  |  | Dosage/Quantity (28 days) |  |  | Refills | |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| COSENTYX 150 mg\u003Cbr> Sensoready® Pen (1x150 mg/mL) | | Prefilled Syringe\u003Cbr>(1x150 mg/mL) |  |  |  Loading Dose: Inject 150 mg subcutaneouslyon Weeks 0, 1, 2, 3\u003Cbr> Maintenance: Inject 150 mg subcutaneouslyon Week 4, then every 4 weeks thereafter |  |  | N/A\u003Cbr>12 refills, | |\n|  |  |  |  |  |  |  |  | or   refills |  |\n| COSENTYX 300 mg  UnoReady® Pen (1x300 mg/2 mL) | | Sensoready® Pen (2x150 mg/mL) | | Prefilled Syringe\u003Cbr>(2x150 mg/mL) |  |  | Loading Dose: Inject 300 mg subcutaneouslyon Weeks 0, 1, 2, 3 | N/A |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  | Maintenance: Inject 300 mg subcutaneouslyon Week 4, then every 4 weeks thereafter | 12 refills,\u003Cbr>or   refills |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  Maintenance Increase (HS only): Inject 300 mg subcutaneously every 2 weeks (For patients currently taking COSENTYX every\u003Cbr>4 weeks as per label. Loading dose already completed.) |  |  | 12 refills,\u003Cbr>or   refills |  |\n\n| Product Information (Pediatric) |  |  |  |  | Dosage/Quantity (28 days) |  |  | Refills | |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| COSENTYX 75 mg (wt \u003C50 kg) | | Prefilled Syringe (1x75 mg/mL) |  |  |  |  | Loading Dose: Inject 75 mg subcutaneouslyon Weeks 0, 1, 2, 3 | N/A | |\n|  |  |  |  |  |  | | Maintenance: Inject 75 mg subcutaneouslyon Week 4, then every 4 weeks thereafter | 12 refills,\u003Cbr>or   refills |  |\n|  |  |  |  |  |  |  |  |  |  |\n| COSENTYX 150 mg (wt ≥50 kg) | | Sensoready® Pen (1x150 mg/mL) | | Prefilled Syringe\u003Cbr>(1x150 mg/mL) |  |  | Loading Dose: Inject 150 mg subcutaneouslyon Weeks 0, 1, 2, 3 Maintenance: Inject 150 mg subcutaneouslyon Week 4,\u003Cbr>then every 4 weeks thereafter | N/A |  |\n|  |  |  |  |  |  |  |  | 12 refills,\u003Cbr>or   refills |  |\n|  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |","cbCaio67hoJnHxKg","https://ap.wps.com/l/cbCaio67hoJnHxKg","pdf",239369,"English","# Patient details\n## Authorization and enrollment consents\n## Insurance/Payer information\n## Prescriber information\n## Product information and dosing (adult)\n## Product information and dosing (pediatric)","[{\"question\":\"Who needs to sign the Patient Authorization and enrollment consents?\",\"answer\":\"The form includes a checkbox for signing by the patient or an authorized representative, with signature and a date (MM/DD/YYYY).\"},{\"question\":\"What consent does the form request for ongoing support?\",\"answer\":\"By checking the box, it agrees to receive recurring marketing calls and texts on behalf of Novartis Patient Support, including possible automatic or pre-recorded communications, with opt-out options.\"},{\"question\":\"What product and dosing schedule details are captured in the enrollment form?\",\"answer\":\"It records Cosentyx product type and dose for adult and pediatric options, including loading and maintenance instructions over Weeks 0–4 and then every 4 weeks thereafter, plus pediatric dosing based on weight and 28-day quantity/refills.\"}]","Patient Authorization and Enrollment Consents - Co-Pay Plus and Ongoing Support | PDF"]