PATIENT AUTHORIZATION I authorize my healthcare providers, pharmacies, and health plan(s) to disclose my personal health information on this form as well as information related to my medical …
Please attach front and back of patient’s insurance card, prescription card, and/or Medicaid card.
Starting AUSTEDO XR® and Getting Your Prescription
See Important Safety Information, including Boxed Warning. Getting your AUSTEDO XR® (deutetrabenazine) extended-release tablets prescription.
Austedo Start Form - Fillable Prescription and Service Request
Austedo (deutetrabenazine) treatment is a prescribed medication for Huntington’s chorea and tardive dyskinesia. Teva Shared Solution, a non-profit organization, allows eligible patients to enroll in the …
Medication q Austedo® Titration Rx q Austedo® q Austedo® XR Strength _________ - week titration q 6mg tablet
Austedo Enrollment Form - Fill and Sign Printable Template Online
Complete Austedo Enrollment Form online with US Legal Forms. Easily fill out PDF blank, edit, and sign them. Save or instantly send your ready documents.
Voucher & Savings Card for AUSTEDO XR®
Find information on AUSTEDO XR® (deutetrabenazine) extended-release tablets 30-Day free trial voucher and copay card.
PRESCRIPTION AND SERVICE REQUEST FORM Please fax completed form to 1-844-257-6126 • For questions, call 1-800-887-8100
Teva Cares Foundation Patient Assistance Program - Requirements & Forms …
The Teva Cares Foundation Patient Assistance Program offers vital support by providing free access to essential medications such as Austedo, Austedo XR, Ajovy, and Uzedy for eligible patients. With a …
Austedo Enrollment Copay Assistance Team 24/7 On call Pharmacist Prior Authorizations Close Clinical Monitoring