Get Amgen Product Replacement Form

The Amgen Product Replacement Form is designed to facilitate the request for product replacements for eligible patients. This guide provides clear and detailed instructions on how to complete this form online, ensuring that users can navigate the process with confidence.

Follow the steps to complete the Amgen Product Replacement Form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Enter the facility name and customer number in the appropriate fields at the top of the form.
3. Complete the shipping address fields, including Shipping Address 1, Shipping Address 2 (if applicable), city, state, and zip code.
4. Fill in the facility contact details, providing the first name, last name, title, phone number, and fax number.
5. Provide the patient’s first name, last name, and date of birth in the corresponding sections.
6. Indicate the product name and unit of measure (selecting Vial, Syringe, or Units from the dropdown).
7. Specify the strength of the vial or syringe and the quantity dispensed.
8. Fill in the administration start and end dates, along with the total number of administrations if applicable.
9. Review the certification statement carefully, ensuring you understand the commitments outlined.
10. Sign the form in the facility contact signature section, or have a physician sign in the designated area. Remember that stamps are not accepted.
11. Include the physician's first and last name, state license number, email, and date of signature.
12. Once all fields are completed, review the form for accuracy, and then save your changes.
13. Download, print, or share the completed form as needed for submission.

Complete your product replacement request online today to ensure timely support for your patients.