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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 Insurance Information Diagnosis Code Medical Assessment Prescriber Information SKYTROFA® Prescription/Dosage and Prescriber Authorization Review
Patient Information
Insurance Information
Diagnosis Code
Medical Assessment
Prescriber Information
SKYTROFA® Prescription/Dosage and Prescriber Authorization
*Required field.
Please select your patient’s GH treatment experience:*
Additional enrollment instructions:

Patient Information

Caregiver Information

*Required field.
Please select the appropriate statement:*

Primary Medical Insurance

Patient Insurance Card (Front)

Patient Insurance Card (Back)

Pharmacy/Rx Insurance

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

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.

ng/mL
ng/mL
cm
kg
%
%
*Required field.
*Required field.

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

kg
mg SKYTROFA®

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

PRESCRIBER AUTHORIZATION: Prescriber certifies that he/she has obtained consent to release the patient’s health information to A·S·A·P in conjunction with the services working solely on behalf of the patient for the purposes of seeking reimbursement through A·S·A·P; verifying insurance coverage; arranging for nursing services; and evaluating the patient’s eligibility for alternate sources of funding, patient support services, and materials and product fulfillment via Specialty Pharmacies. The prescriber is to comply with his/her state-specific prescription requirements such as e-prescribing, state-specific prescription form, fax language, etc. Noncompliance with state-specific requirements could result in outreach to the prescriber. I authorize A·S·A·P to transmit this prescription to the appropriate pharmacy designated by the patient utilizing their benefit plan.

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.

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.