File name: Austedo Patient Assistance Form Pdf
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👉Austedo Patient Assistance Form Pdf
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May 30,  · Please attach front and back of patient’s insurance card, prescription card, and/or Medicaid card. 3 CLINICAL INFORMATION G Tardive Dyskinesia (TD): Please fax . Note: A Patient’s Personal Representative may sign this Form on behalf of the Patient. However, only certain individuals may qualify as the Patient’s Personal Representative. PRESCRIPTION AND SERVICE REQUEST FORM Please fax COMPLETED form to • For questions, call • 8 am–8 pm CT M–F AUSTEDO® . Austedo Enrollment Form - Copay Assistance Team - 24/7 On call Pharmacist - Prior Authorizations - Close Clinical Monitoring *This is not a valid prescription. PRESCRIPTION AND SERVICE REQUEST FORM Please fax COMPLETED form to • For questions, call • 8 am–8 pm CT M–F AUSTEDO® (deutetrabenazine) tablets PATIENT OR PERSONAL REPRESENTATIVE SIGNATURE: If signed by someone other than the patient, complete the following information. Patients can start AUSTEDO XR for $0 with day Free Trial Voucher. Additional financial assistance support available for eligible patients.* Request a visit from an ARM or ask your Teva Sales Representative to connect you with your local ARM for more information.