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Your Enrollment Form request has been submitted to IPSEN CARES for review. A Patient Access Specialist will review your submission and contact both you and your Healthcare Provider within 1 business day. If you have any questions or would like to learn more about IPSEN CARES and its support offerings, please call 866-435-5677, 8:00am to 8:00pm ET Monday through Friday.
Please note: This form will take 10 minutes to complete. There is a requirement for two signatures - first the patient, then the HCP office. If you are applying for PAP, we do have a process for 3rd party verification authorization which would require an additional signature.
Instructions for Patients
- Your Healthcare Provider will complete the Steps Outlined in Teal.
- You need to complete Steps 2 through 6 Outlined in Orange on the Enrollment Form.
- Fill out all sections completely. Missing information could delay your enrollment in IPSEN CARES.
- STEP 2: Fill out the Patient Information Section in Step 2.
- STEP 3: Fill out the Insurance Information Section in Step 3.
- STEP 4: Sign the PATIENT AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION in Step 6.
Instructions for Prescribers
- Fill out the Prescriber Information Sections in Steps 1, 7-10.
- Sign and date the PRESCRIBER/OFFICE MANAGER ATTESTATION at the end of Step 7B.
- Step 5 is required for PAP Enrollment Only.
Once a completed Enrollment Form is received, an IPSEN CARES Patient Access Specialist will perform a benefits verification and review the patient’s coverage and out-of-pocket responsibility with both the HCP and the patient typically within 1 business day. To learn more about IPSEN CARES and support offerings, please call 866-435-5677, 8:00 am to 8:00 pm ET Monday through Friday or visit www.ipsencares.com.