Product Replacement - 博彩平台网址大全 Corporate-博彩平台网址大全

Specialty Pharmacy Information

NOTE: If you are a hospital-based Specialty Pharmacy, please complete the Site of Care form

Specialty Pharmacy Name(Required)

Specialty Pharmacy Representative Name(Required)

Specialty Pharmacy Representative Title(Required)

Email Address(Required)

Patient Information

Patient Initials(Required)

Date of Birth(Required)

RareConnections Patient ID Number(Required)

SP Patient ID(Required)

Prescribed 博彩平台网址大全 Product (the “Product”)(Required)

Kuvan® Dosage

Palynziq® Dosage

VOXZOGO® Dosage

Amount/Description of Product Rendered Unsaleable(Required)

Specialty Pharmacy Attestation On Behalf of the Patient

Please enter your 博彩平台网址大全 PR#

Additional Information

(^†) For multi-unit packaging configuration, the unused Product pack will be returned to 博彩平台网址大全 or the entire Product pack must be destroyed.

If 博彩平台网址大全 approves the patient’s request for replacement medication, I shall communicate to the patient that (i) the replacement medication will be provided to the patient at no charge, (ii) there is no purchase requirement associated with the patient’s receipt of the replacement medication, (iii) the replacement medication is not intended as a reward or inducement for the purchase of any product, and (iv) the patient may not resell or transfer the replacement medication to any other individual or entity for any purpose.

By entering my name below and submitting this form, I hereby attest that the information provided in the form above is true and correct.

Specialty Pharmacy Representative Name(Required)

Date(Required)

Specialty Pharmacy Representative Title(Required)

Upload Product Image

Max. file size: 5 MB.

Please upload a single image of Product damage, if available, (jpeg, gif, png, pdf format only, not to exceed 5 MB in size) or check the box to confirm that no photo of Product damage or impairment is available.

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博彩平台网址大全 Product Replacement (U.S. Only)

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Specialty Pharmacy Information

Patient Information

Specialty Pharmacy Attestation On Behalf of the Patient

Provider Information

Provider Attestation

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