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Please fax all pages of completed form to your team at 888.454.8488. Web immediately notify the sender by telephone and destroy the original fax message. Web acthar ® gel (repository corticotropin injection) is indicated for: Explore each subject in depth.
Complete Pages 1 And 2 Of The Acthar Referral Form.
Web acthar gel is a prescription medicine used for: The deadline for completed forms and references is friday 22nd december 2023. Web prescription & enrollment form. Web download an enrollment form.
If Patients Do Not Have Insurance Coverage, They May Be Able To Receive Financial Support Through The Acthar Patient.
Your prescriber will submit the completed acthar referral form to acthar patient support. Email or fax the completed acthar referral form along with clinical notes, any medically relevant. Web download the referral form. With the availability of cortrophin gel, both patients and healthcare professionals now have access to another.
Start The Acthar Gel Prescription.
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