Downloadable Forms
Privacy Notice and Patient Authorization Form for the Prolia® Co-pay Program
Check Request Form for the Prolia® Co-pay
Program
Electronic Funds Transfer (EFT) Authorization Form for the Prolia® Co-pay Program
IMPORTANT UPDATE:
For 2022, we are implementing an automatic re-enrollment process which will automatically extend any patient with activity in 2021 through 2022. This means there is no action required to re-enroll a patient at this time. Patients may continue to utilize their copay benefits and you may submit explanation of benefits (EOBs) as normal.