ENROLLMENT ASSISTANCE
Use this form as a guide for completing the enrollment form.
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 review the enrollment options below to access The Organon Access Program and choose the method that best works for you and your patient. If your patient is requesting a referral to the Organon Patient Assistance Program, be sure to include all information, including a prescription for ONTRUZANT, which you can now complete on the enrollment form. Please be sure all signatures are included prior to submitting forms to The Organon Access Program.
Option
1
Electronic Enrollment
via CoverMyMeds
Click to enroll
Allows providers to electronically enroll patients into
The Organon Access Program and initiate other access services.
With CoverMyMeds, you can:
- Perform benefits investigations and submit prior authorizations
- Access the Organon Co-pay Assistance Program
- Track patient case status
- Submit prescriptions
Patients can sign and submit the enrollment form electronically using DocuSign
Looking for the DocuSign Provider and Patient Enrollment Form? Option 1 (Electronic Enrollment) has replaced that form.
For help submitting that form via CoverMyMeds, call 844-326-2986.
Option 1
Electronic Enrollment
via CoverMyMeds
Click to enroll
Allows providers to electronically enroll patients into
The Organon Access Program and initiate other access services.
With CoverMyMeds, you can:
- Perform benefits investigations and submit prior authorizations
- Access the Organon Co-pay Assistance Program
- Track patient case status
- Submit prescriptions
Option 2
Download, Print & Fax
DOWNLOAD THE 2023
ENROLLMENT FORM
Download this form to fill out, print, and fax.
Patients can sign and submit the enrollment form electronically using DocuSign
Looking for the DocuSign Provider and Patient Enrollment Form? Option 1 (Electronic Enrollment) has replaced that form.
For help submitting that form via CoverMyMeds, call 844-326-2986.
ENROLLMENT ASSISTANCE
2023 SAMPLE
ENROLLMENT FORM
Use this form as a guide for completing the
enrollment form.
