Bellaire Dermatology POC

Guided Workflow

Taltz / Lilly Support Services

POC demo using fake patient data. Output is a secure download link.

Dark Grey POC

First name Last name Date of birth Phone Address City State ZIP

Insurance company Member ID Group number PBM Prior authorization needed

Prescriber name NPI Clinic name Clinic phone Clinic fax Clinic address

Enrollment support Benefits investigation Prior authorization support Patient assistance option

Patient Signature

Signature date

Provider Signature

Signature date