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TABLETS AND OTHER DOSAGE FORMS: ViiVCONNECT ENROLLMENT FORMS

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Complete the ViiVConnect Enrollment Form for tablets and other dosage forms* to obtain comprehensive information on access and coverage for prescribed ViiV Healthcare medicines. Once the form has been submitted, an Access Coordinator can begin verifying insurance benefits and helping patients answer questions regarding access and coverage for their prescribed ViiV Healthcare medicines. Enrollment in ViiVConnect is not required for patients to access their prescribed ViiV Healthcare medicines.

Here’s some of the information needed to complete the ViiVConnect Enrollment Form:

Patient information

Including name, date of birth, address, and phone

Insurance information (if applicable)

Including health insurance and pharmacy card information

Prescription information

Including medication name and dosage

Prescriber information

Including prescriber name, contact information, Tax ID, NPI, and State License number

(Patients can contact the doctor’s office or pharmacy for help filling out this section.)

For patients applying for assistance 

If a patient doesn't have insurance and is having trouble paying for their prescribed ViiV Healthcare medicine(s), the patient may qualify for the Patient Assistance Program (PAP).

To see if a patient may be eligible for PAP, review program requirements. 

Have questions?

If you need help completing or submitting the enrollment form, an Access Coordinator can assist you. Call 1-844-588-3288 (toll free) to speak live with an Access Coordinator.

*Other ViiV Healthcare medicines include: tablets, oral solutions, an oral suspension, capsules, syrup, and an injection, for intravenous use.

Subject to eligibility, program terms and conditions. ViiVConnect programs do not constitute health insurance.

Patient eSignature Authorization

Patients must sign the form to be eligible for ViiVConnect enrollment.  If you are unable to manually sign, use this link to sign electronically if an enrollment form was submitted without the required patient signature.

Download and Complete the
ViiVConnect Enrollment Form for Tablets and Other Dosage Forms*

Healthcare Professionals, Pharmacists, and Patient Representatives may register in the ViiVConnect Portal to assist their patients with the ViiVConnect enrollment process for prescribed ViiV medicines.

Submit the ViiVConnect
Enrollment Form

Fax:

1-844-208-7676

Mail:

ViiVConnect Enrollment  |  PO Box 220100 Charlotte, NC  28222-0100

ENROLL BY PHONE:

Call our live Access Coordinator team to enroll patients over the phone at 1-844-588-3288 (toll free).

ENROLL ONLINE:

For Healthcare Professionals, Pharmacists, and Patient Representatives Only

Once the ViiVConnect Enrollment Form is received, an Access Coordinator may contact you regarding insurance coverage for prescribed ViiV medicines and eligibility for ViiVConnect programs.

Patient eSignature Authorization

Patients must sign the form to be eligible for ViiVConnect enrollment. If you are unable to manually sign, use this link to sign electronically if an enrollment form was submitted without the required patient signature.

NEED HELP? TALK ONE-ON-ONE LIVE WITH OUR ACCESS COORDINATORS   
1-844-588-3288 (toll free)

We have programs for eligible patients who are insured, underinsured, and uninsured. 
Monday - Friday, 8AM - 11PM (ET).
Multilingual options available.

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