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
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.
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