Mirati & Me Patient Support Program Enrollment Form

Mirati & Me Patient Support Program Enrollment Form

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Complete all sections and submit to enroll.

Please note, incomplete forms will not be saved for submission later.

You may submit the patient’s prescription directly to the Mirati & Me pharmacy by selecting PharmaCord Pharmacy in your respective electronic health record (EHR):

If you are unable to submit the patient’s prescription via EHR, simply fax Mirati & Me at 1-502-805-3530.

If you need additional assistance, please call Mirati & Me, available Monday-Friday
8 AM to 8 PM ET at
1-844-647-2842.

What Is Required to Receive Support?

Please see the required information below for each requested type of support. These requirements apply only for support through Mirati & Me and are not intended to limit any treatment, payment, or benefit activities with your pharmacy or other healthcare providers.

Support Requested (check all that apply)

Support Requested Form

Require faxed copies of health insurance and prescription drug coverage cards

Prescriber and patient signatures required

Prescriber and patient signatures required

Prescriber and patient signatures required

Savings Card Assistance

Valid prescription required

Visit our Savings Card Site

Free Trial Offer

Valid prescription, prescriber,
and patient signatures required

Visit our Free Trial Offer Site