Enrollment Form

The Prescriber must sign if this form is to be used as a prescription to be triaged to a Specialty Pharmacy, to enroll a patient for free goods as part of the Patient Assistance Program (PAP), or to enroll a patient for free goods as part of the Temporary Patient Assistance Program (TPAP), or to enroll a eligible commercially insured patient who can pay as little as $0 on their out of pocket medication cost. If the request is limited to benefit verification or copay assistance support, the prescriber, or an individual acting at the direction of the prescriber and involved in the patient’s care (such as an office practice manager, financial coordinator, financial counselor, patient assistance coordinator, patient navigator, social worker, insurance coordinator, patient coordinator, or patient care advocate) may sign this form.

By signing below, I certify that the therapy referenced in this form is medically necessary and that I have received the necessary authorization to release the information herein and medical and/or patient information relating to therapy to Ipsen and its agents or contractors for the purpose of seeking reimbursement for the Ipsen therapy and assisting in initiating or continuing the Ipsen therapy. I authorize Ipsen to be my agent and to forward the above prescription, by fax or other mode of delivery, to the appropriate pharmacy. If required by your state, please provide all prescriptions on an official state prescription form to ensure compliance.

I certify that any medications provided by Ipsen in connection with any IPSEN CARES program will be used only for the named patient. These medications will not be offered for sale, trade, or barter. I acknowledge that I have assisted the named patient in enrolling in IPSEN CARES exclusively for the purposes of patient care and not in consideration for, expectation of, or actual receipt of remuneration of any sort. I consent to contact by Ipsen representatives about the program, my patient’s participation in the program, or the prescribed medication.

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