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Statement of Medical Necessity

Enroll a Patient in the Ascendis Signature Access Program® (A·S·A·P)

Thank you!

The Statement of Medical Necessity form has successfully submitted.

In order to complete your patient's enrollment, please submit an e-prescription to our program's pharmacy (NPI: 1699202838), or fax a written prescription to our program at 1-888-436-0193.

Patient Information Authorization Insurance Diagnosis Medical Assessment Preferred Specialty Pharmacy Prescriber Information SKYTROFA® Prescription/Dosage and Prescriber Authorization Training Authorization Review Your Submission
Patient Information Authorization
Insurance
Diagnosis
Medical Assessment
Preferred Specialty Pharmacy
Prescriber Information
SKYTROFA® Prescription/Dosage and Prescriber Authorization
Training Authorization
Review Your Submission

Patient Information Authorization

*Required field.
Please select your patient's growth hormone (GH) treatment experience:*
Additional enrollment instructions:
†For Auto-Injector only, must include evidence of an approved claim by insurance.

Insurance

*Required field.
Please select the appropriate statement:*

Patient Insurance Card (Front)

Patient Insurance Card (Back)

Prior Authorization (PA) Submitted:
PA Approval:

Diagnosis

*Required field.
Please check the applicable ICD-10 diagnosis code. Pediatric GH deficiency (GHD):*

Medical Assessment

*Required field.

Completing the Medical Assessment section is crucial for verification

Missing information can slow the verification process, insurance authorization, and treatment fulfillment. In the event of key information being missing from the SMN form, your office may be contacted as patient-specific plan details are entered into our system.

kg
%
cm
%
cm/yr
MRI (pituitary gland) completed:
ng/mL
ng/mL

Preferred Specialty Pharmacy:

Prescriber Information

*Required field.

SKYTROFA® Prescription/Dosage and Prescriber Authorization:

*Required field.

Recommended weight-based dosing ranges are based on 0.24 mg/kg/week.

kg
mg

The SKYTROFA Auto-Injector is packaged in a separate carton.

By signing below, I certify that: (a) I am a licensed practitioner, in good standing under applicable state law; (b) the information I have provided on this enrollment form is, to the best of my knowledge, true, complete, and accurate; and (c) I have obtained the necessary authorization from the patient, patient's caregiver, and/or legal representative to use, disclose, share, or otherwise release the above information, including the patient's protected health information (“PHI”) for the purpose of providing patient assistance, including verifying insurance coverage, arranging training services, and evaluating patient's eligibility for alternate sources of funding. Further, I appoint the Ascendis Signature Access Program® (“A·S·A·P”), on my behalf, to convey this prescription to the dispensing pharmacy. I will immediately notify Ascendis Pharma if the above-named patient, individually or through their caregiver, and/or legal representative, revokes their consent. I give you permission to contact me, or the above-named patient, patient's caregiver, and/or legal representative.

Please note that the authorization you are providing is not a valid prescription. In order to complete your patient's enrollment, please submit an e-prescription to our program's pharmacy (NPI: 1699202838), or fax a written prescription to our program at 1-888-436-0193.

Nurse Injection Training Authorization

A·S·A·P will provide my patient and/or his/her caregiver with training from a company-funded clinical nurse educator on the proper self-administration of SKYTROFA. I am requesting A·S·A·P to coordinate a nurse to provide SKYTROFA self-administration training for my patient. I will receive information on my patient's injection training via the fax number I provided above. This order is valid for 1 year.

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Review your submission

Please click the Review button below if you wish to check the accuracy of the information provided. When ready, click the Submit button. A confirmation message will appear when the form has successfully submitted.