eSignature Form

This site is intended for US residents 18 years of age or older.

Patient eSignature
Authorization Form

Welcome to the Patient eSignature Authorization Form page for ViiVConnect.

If a ViiVConnect Enrollment Form has been completed and submitted to ViiVConnect (by fax, mail, or phone), but you were unable to sign it, you may use the abbreviated form below to provide your signature electronically, so that we can process the Enrollment Form that you or your healthcare provider previously submitted.

 

1. Click the link below to complete the steps for your eSignature.

2. You will need to provide the following information:

First Name, Last Name, Date of Birth, ZIP Code

Do You Need Help?

Talk one-on-one live with a dedicated Access Coordinator.

Call 1-844-588-3288 (toll free) Monday – Friday, 8AM – 11PM (ET).

Multilingual options available.

Patient Authorization & Agreement Forms

Patient eSignature Authorization Form

Category

ViiVConnect

Action

MRVWCNT210005