Get Keveyis Start Form - Keveyis.com

Filling out the KEVEYIS Start Form is an essential step in accessing the necessary support for KEVEYIS treatment. This guide will provide clear and concise instructions to help users complete the form accurately and efficiently.

Follow the steps to properly complete the KEVEYIS Start Form.

1. Click the ‘Get Form’ button to obtain the form and open it in your browser or document editor.
2. Ensure that you complete all fields on the form to prevent delays in processing. This includes personal information, such as first name, last name, date of birth, and contact information.
3. If possible, obtain the patient’s signature for HIPAA authorization. This is essential for sharing medical information with healthcare providers.
4. Provide detailed prescription drug insurance information. Fill in both primary and secondary insurance details if applicable, including cardholder names and relationships.
5. In the authorization section, understand that by signing, you allow healthcare providers to share your information with Strongbridge Biopharma for assistance with KEVEYIS treatment.
6. Fill in clinical information, including diagnosis and allergies, to ensure accurate medical context.
7. Provide prescriber information accurately, including name, contact details, and NPI or DEA numbers, if applicable.
8. In the prescription section, confirm the medication prescribed and any refill instructions, and include the prescriber’s signature to validate the prescription.
9. Once all fields are completed, review the form thoroughly to ensure accuracy. After confirming all information is correct, you can save the changes, download, print, or share the form as needed.

Complete your KEVEYIS Start Form online today to access the support you need.