Before prescribing ONTRUZANT, please read the accompanying
Prescribing Information, including the Boxed Warning about cardiomyopathy,
infusion reactions (pulmonary toxicity), and embryo-fetal toxicity.
ENROLL NOW
Please click on the links below to access The Organon Access Program forms that are applicable to you. If your patient is requesting a referral to the Organon Patient Assistance Program, be sure to include all information, including a prescription for ONTRUZANT. Please be sure all signatures are included prior to submitting forms to The Organon Access Program.
DOWNLOAD
& PRINT
These forms can be downloaded and
printed, and require an original signature.
SIGN & SUBMIT
ELECTRONICALLY
These forms can be signed and
submitted electronically.
Patient in Office
Use these forms if the patient is in the office and
you are able to complete the form together.
Use this form if you would like to re-enroll your
patients for 2023.
Patient Not in Office
Use these forms when the patient is not in the office
to complete the forms with you. Use this form if you
would like to re-enroll your patients for 2023.
The patient must also submit the
Electronic Patient Enrollment Form.
ENROLLMENT ASSISTANCE
Download and use this form as a guide
for completing the enrollment form.
