The Paxman Hub Enrollment Form is the single document that gets you from a scalp cooling referral to an actual cap at your first chemotherapy session. You fill out the patient and insurance sections, your oncologist fills out the clinical section, both of you sign, and the completed form goes to the Paxman Hub by fax at 888-358-0410.1Paxman Scalp Cooling. Insurance-Based Billing Steps Within one to three business days, the Hub runs a benefits investigation and sends back a Summary of Benefits showing what your insurer will cover and what, if anything, you’ll owe.
Before You Start
The form is only used at treatment centers that have signed a contract with Paxman and its distributor under the Insurance-Based Billing Model, so confirm with your oncology practice that scalp cooling is offered on site.2Paxman Scalp Cooling. US Access and Support You can download the form from paxmanscalpcooling.com or the patient site at coldcap.com, and many infusion centers keep printed copies.3Paxman Scalp Cooling. Paxman Hub Enrollment Form
One boundary to know: the device is FDA-cleared for solid tumors, and it has clinical contraindications that rule out certain patients, including those with blood cancers, brain tumors, head and neck cancers, scalp metastases, cold-sensitivity conditions, and pediatric patients.4U.S. Food and Drug Administration. 510(k) Clearance Letter K173032 – Paxman Scalp Cooler Your oncologist screens for these before signing. If you’re uncertain whether scalp cooling fits your case, raise it at your treatment planning visit rather than at form-signing time.
Section 1: Patient Information
The top of the form is yours. Enter your full legal name exactly as it appears on your insurance card, your date of birth, sex, home address, mobile and home phone numbers, and email.3Paxman Scalp Cooling. Paxman Hub Enrollment Form The address isn’t just for mail. If your treatment center uses direct-to-patient delivery, the cooling cap kit ships there. A misspelled name or outdated address is one of the easiest ways to stall the process before it starts.
Section 2: Prescriber and Clinical Details
Your oncologist completes this section. It asks for the physician’s name, practice name, office address, phone, fax, and National Provider Identifier. The NPI is the ten-digit number assigned to every healthcare provider for insurance billing and administrative transactions.5Centers for Medicare & Medicaid Services. National Provider Identifier Standard Without an accurate NPI, the Hub cannot run the benefits investigation.
The clinical lines ask for your specific ICD-10 diagnosis code (for example, C50.919 for malignant neoplasm of unspecified site of unspecified female breast), the chemotherapy drugs in your regimen, and the scheduled start date.6AAPC. ICD-10-CM Code C50.919 The Hub uses this information to confirm your protocol is compatible with scalp cooling and to time delivery to your first infusion.
Section 3: Insurance Information
Section 3 is where the Hub gets what it needs to verify your coverage. Provide your primary insurance company name, policy number, and group number, and include secondary coverage if you have it. The form lets you attach a copy of the front and back of your insurance card instead of transcribing every field, which cuts down on errors.3Paxman Scalp Cooling. Paxman Hub Enrollment Form
Coverage for scalp cooling varies widely by plan and state. New York and Louisiana now require large-group health insurers to cover scalp cooling systems; if you live in one of those states and have a qualifying plan, your benefits summary should reflect that.7Centers for Medicare & Medicaid Services. Billing and Coding – Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia Elsewhere, outcomes range from full coverage to flat denial, which is why completing the next section matters even if you think your insurance will pay.
Section 4: Financial Assistance Screening
If you leave the financial section blank and your insurance comes back short, the Hub cannot automatically screen you for the Patient Assistance Program. Fill it out even if you expect coverage.8Paxman Scalp Cooling. Paxman Insurance-Based Billing Model – Procurement Explained The PAP provides the cap at no cost to patients who are uninsured or underinsured and meet income limits.9Paxman Scalp Cooling. Paxman Patient Assistance Program
To qualify, your total household income must fall at or below six times the federal poverty level. Using the 2025 HHS poverty guidelines for the 48 contiguous states, the thresholds work out to roughly:10Federal Register. Annual Update of the HHS Poverty Guidelines
- 1 person: $93,900
- 2 people: $126,900
- 3 people: $159,900
- 4 people: $192,900
Alaska and Hawaii have higher thresholds. The form asks for your current annual household income, employment status, and household size. Paxman may request tax returns, pay stubs, or similar records to verify what you report, and may conduct periodic audits.9Paxman Scalp Cooling. Paxman Patient Assistance Program
Signatures and Submission
Both you and your prescribing physician must sign before the form goes to the Hub.11Paxman Scalp Cooling. Paxman Insurance-Based Billing Model – Billing Explained Your signature authorizes your providers, pharmacies, and insurers to share personal health information with the Hub so it can coordinate benefits, verify insurance, and arrange delivery on your behalf.3Paxman Scalp Cooling. Paxman Hub Enrollment Form
Fax the completed form to the Paxman Hub at 888-358-0410.1Paxman Scalp Cooling. Insurance-Based Billing Steps Fax is the submission method printed on the form itself; the main enrollment form does not list an email option. If you’re submitting a standalone Patient Assistance Program application, that one can also be emailed to pap@paxmanusa.com. For questions before you send anything, the Paxman USA Hub answers at 844-572-9626, Monday through Friday, 8 a.m. to 8 p.m. Eastern.12Paxman Scalp Cooling. Contact Us
What Happens After You Submit
Within one to three business days of receiving a complete form, the Hub returns a Summary of Benefits.1Paxman Scalp Cooling. Insurance-Based Billing Steps It lands in one of three places:8Paxman Scalp Cooling. Paxman Insurance-Based Billing Model – Procurement Explained
- Coverage confirmed. The Summary spells out your co-pays or coinsurance, and the process moves to shipping.
- No coverage or high out-of-pocket cost. If you completed the financial section, the Hub screens you for the PAP.
- Prior authorization required. Your treatment site submits the PA request directly to your insurer; the Hub helps coordinate.
A case manager will call you to walk through the results and confirm the shipping destination. Answer promptly. Silence from the patient is the most common reason delivery slips past the first chemotherapy session.
If Your Insurer Denies Coverage
The Hub supports your treatment facility through the appeals process and provides a sample appeal letter your oncologist can customize.13Paxman Scalp Cooling. About the Paxman Scalp Cooling HUB Services and Patient Assistance Program Model Your provider should check the insurer’s specific appeal rules (portal versus fax, internal deadlines) before sending anything. While the appeal is pending, you’re still screened for the PAP, so treatment doesn’t have to wait on the insurer.