Patient Enrollment Form
Download the enrollment form:
Fax it to:
1-844-208-7676 (toll free)
Mail it to:
ViiVConnect Enrollment
PO Box 220100
Charlotte, NC 28222-0100
Upon receipt of enrollment form, a dedicated Access Coordinator will contact you.
ViiVConnect Portal
For Healthcare Professionals, Pharmacists, and Patient Representatives:
- Secure online application
- Online patient enrollment
- Verify and track coverage
- Submit prior authorizations
Learn More
ViiVConnect Portal
For Healthcare Professionals, Pharmacists, and Patient Representatives:
Enroll patients 24/7 to verify and track coverage with our secure online resource tool.
Learn more about the portal