Mirati & Me Patient Support Program Enrollment Form

Mirati & Me Patient Support Program Enrollment Form

  • Patient Information
  • Insurance Information
  • Prescriber Information
  • Prescriber Authorization

Patient Information

Contact Consent

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Insurance Information

Primary Insurance

Secondary Insurance

Prescription Insurance

Prescriber Information

Office Contact Information

Prescriber Authorization

By signing below, I certify that I am the physician or a designated agent of the healthcare provider/practice, who has prescribed KRAZATI® (adagrasib) (the “Product”), which is medically necessary for this patient and the information provided on this form is accurate to the best of my knowledge. I have obtained the patient’s authorization as required by the Health Insurance Portability and Accountability Act (“HIPAA”) to use and disclose the patient’s personally identifiable health information (“PHI”) on this form to the patient’s other healthcare providers (including pharmacies and Mirati), health insurers, and other designees that are involved in the patient’s treatment for the purposes of preliminary insurance verification and to assess the patient’s eligibility for participation in Mirati & Me. I agree that Mirati may contact me for additional information relating to Mirati & Me or the patient’s therapy. I understand that any Product provided at no charge to the patient is provided on a complimentary basis. I will not submit or cause to be submitted any claims for payment of such Product to any third-party payer, including, without limitation, a federal healthcare program. If I am or become in possession of such Product, I will not resell or attempt to resell the Product. I agree to comply with Mirati & Me guidelines and understand that Mirati reserves the right to modify or discontinue Mirati & Me at any time.

Prescriber shall comply with applicable state prescribing requirements, such as e-prescribing, state-specific prescription form(s), fax language, etc. Noncompliance with applicable state prescribing requirements could result in additional communications from Mirati & Me or other contractors to the prescriber.