Patient eSignature Authorization Form
Welcome to the Patient eSignature Authorization form page for ViiVConnect.
If a ViiVConnect Patient 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 Patient 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
Dedicated Access Coordinators can explain the features and benefits of ViiVConnect. Learn more about programs for eligible patients who are insured, underinsured, and uninsured.
Talk one-on-one live with a dedicated Access Coordinator. 1-844-588-3288 (toll free) Monday – Friday, 8AM – 11PM (ET) Multilingual options available.
|ViiVConnect Patient eSignature Authorization Form||Sign Electronically|