This form allows you to get your patients started on UPTRAVI. The Patient Enrollment form is not optimized for mobile devices. Please print, sign, and fax to Actelion Pathways®.
- 1.Fill in the required fields so the specialty pharmacy is able to contact the patient directly.
- 2.Option to indicate the preferred specialty pharmacy on the cover sheet.
- 3.Please select one of the 2 titration dosing instruction options.
- 4.Both the physician's signature and the date are required, as well as a copy of the patient's insurance card.
- 5.Please check the appropriate ICD code.
- 6.Check that the patient has signed, dated, and completed all of the required fields. Note: Enrollment in Actelion Pathways® (Section 7 of the form) is recommended but not mandatory.
Note: An alternate form is available for VA patients
UPTRAVI VA Patient Enrollment Form
This guide offers dosing, titration, and pill identification information to help you get your patients get started on UPTRAVI.
A patient guide that highlights the important steps and information about titration with UPTRAVI.