KERAGEL / KERAMATRIX PRESCRIPTION SUPPORT

    PATIENT SOLUTIONS ENROLLMENT FORM

    Please fax this completed form to 888-608-0520 or
    email mbpatientsupport@rxtalents.com
    You may also call us at 888-608-0698

    Print Blank Enrollment Form
    Print Blank Prescription Form

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    Step 1 Enrollment

    Please fax or email the prescription and completed enrollment form along with copies of all insurance and prescription cards.

    Step 2 Keeping You Informed

    When approval is received, you will be contacted by RxTalents and asked to complete a registration form for Diamond Pharmacy to fill your prescription.

    1PATIENT INFORMATION

    MaleFemaleOther

    2Insurance Information

    Please Include Copies of All Available Insurances and Prescription Cards (Front and Back)

    3Required for Keragel Financial Assistance Program for Uninsured or Underinsured Patients

    (Please include before tax wages, pension, interest/dividends, social security benefits, and any other sources of income)

    4PRESCRIBER INFORMATION

    5TREATMENT INFORMATION

    6AUTHORIZATION TO RELEASE PERSONAL HEALTH INFORMATION

    By signing this Authorization to Release Health Information, I authorize my health care providers, pharmacies, health plans, and insurers (and contracted services) to disclose to Molecular Biologicals and its third-party business partners information about my insurance coverage, diagnosis, disease, treatment, and payment for my treatment for the purpose of obtaining patient support services including investigation of my health insurance coverage, communicating with me about my experience, providing support services, and operating and administering the program. I understand that once my
    information has been released to Molecular Biologicals and its affiliates, federal privacy laws may no longer protect the information from further disclosure, but that Molecular Biologicals and affiliates intend to use this information for purposes of this authorization or otherwise allowed by law. I understand I may refuse to sign this authorization and it will not impact my ability to obtain medical care, insurance coverage, or access to health benefits including access to treatment. However, by not signing, Molecular Biologicals
    can not provide these support services. This authorization will expire after two years from the date I signed. I may decide to withdraw this authorization at any time by sending a written notice that includes my name, address, and phone number to RxTalents, LLC ATTN: Patient Services, 4900 Carlisle Pike, Mechanicsburg, PA 17050

    By signing below, I certify that I have read and understood the Authorization to Release Personal Health Information and agree to its terms. I understand that I may request a copy of this Authorization.

    7FINANCIAL ASSISTANCE PROGRAM PATIENT AUTHORIZATION

    I acknowledge that my personal and insurance information stated on this form is correct. I acknowledge that I am responsible for paying any out-of-pocket expenses up to the program maximum. I authorize Molecular Biologicals and its affiliates to contact me by mail, phone, cell phone, voice mail, email, or text message regarding the financial assistance program and insurance information.

    By signing below, I certify that I have read and understood the Financial Assistance Program Authorization and agree to its terms.

    Additional Information Needed:

    A Prescription from your doctor for Keragel / Keramatrix / Keragel T
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