Veloxis Transplant Support Enrollment Form

Enrolling in Veloxis Transplant Support

Veloxis has created the Veloxis Transplant Support program to assist patients in obtaining access to Veloxis medications. Applications are reviewed and eligibility is verified. Determinations are made on a case-by-case basis using pre-determined eligibility requirements regarding coverage and financial criteria.

After the Form has been submitted, including Financial Documentation and Insurance Cards, your Veloxis Transplant Support (VTS) Specialist will review the application and then notify both provider and patient of next steps.
Patient Assistance Program Details

Patients enrolled in patient assistance are approved for a maximum of 12 months of eligibility at a time and must reapply to re-validate their eligibility annually. VTS will contact you to re-validate your eligibility for Patient Assistance before the current eligibility period expires.

Note for Medicare Part D Participants: When interfacing with a Medicare Part D beneﬁciary, the Veloxis PAP will operate outside of the Medicare Part D beneﬁt. Any assistance provided to a patient for drugs that would have been covered under their Part D plan will not count as an incurred cost that would be applied toward the enrollee’s TrOOP balance or total drug spend.
Download Enrollment Form (PDF)
➝ English / ➝ Español

Veloxis Transplant Support Prescription Form
Download Here

Designation of Agency Form
Download Here
Requesting the following, please check all that apply: (based on eligibility; please include the appeal denial if you have it to expedite the process){{Application type}} *

Requesting the following, please check all that apply: (based on eligibility; please include the appeal denial if you have it to expedite the process){{Application type}} Benefits Investigation Bridge Supply Patient Assistance Program (PAP) enrollment
Patient Contact Information
1. First Name{{Patient First Name}} *
2. Middle Name
3. Last Name{{Patient Last Name}} *
4. Date of Birth{{DOB}} 4. Date of Birth{{DOB}} * / MM / DD YYYY

This field is required
5. Home Address *
6. City *
7. State{{State}} *
8. Zip Code *
9. Home Phone # 9. Home Phone # * - ### - ### ####
10. Cell Phone # 10. Cell Phone # - ### - ### ####
11. Email
12. Preferred contact method (select one):{{Patient Preferred contact method}}

12. Preferred contact method (select one):{{Patient Preferred contact method}} Phone Call Text Email
13. Preferred time to contact (select one):

13. Preferred time to contact (select one): Morning Afternoon Evening
14. Ok to Text? (Select one)

14. Ok to Text? (Select one) Yes No
15. Ok to leave voicemail? (Select one)

15. Ok to leave voicemail? (Select one) Yes No
16. Preferred Language:{{Preferred language}}
Patient Insurance Information

(Please upload copies of both sides of patient applicant's insurance cards)
Does the patient have pharmacy benefit insurance? *

Does the patient have pharmacy benefit insurance? Yes No
17. Pharmacy Benefit Plan Name:
17(a). Policy Holder Name
17(b). Insurance Phone #: 17(b). Insurance Phone #: - ### - ### ####
17(c). Rx BIN:
17(d). Rx PCN:
17(e). ID #:
17(f). Rx Group #:
18. Patient has (check all that apply): *

18. Patient has (check all that apply): No Insurance Medicare B Medicare Advantage Medicare Part D Medicaid Private/Commercial Government (Tricare/VA)
19. Primary Insurance

(Please upload copies of both sides of patient applicant's insurance cards)
19(a). Primary Insurance Name:
19(b). Policy Holder Name: 19(b). Policy Holder Name: First Last
19(c). Insurance Phone #: 19(c). Insurance Phone #: - ### - ### ####
19(d). Policy ID #:
19(e). Group ID #:
Upload Primary Insurance Card Image (optional):

Attach Files
Does the patient have secondary insurance? *

Does the patient have secondary insurance? Yes No
20(a). Secondary Insurance Name:
20(b). Policy Holder Name: 20(b). Policy Holder Name: First Last
20(c). Insurance Phone #: 20(c). Insurance Phone #: - ### - ### ####
20(d). Policy ID #:
20(e). Group ID #:
Upload Secondary Insurance Card Image (optional):

Attach Files
Healthcare Provider Information
21. First Name *
22. Last Name *
23. Specialty
24. Title (select one):

24. Title (select one): MD NP DO PA other (specify): other (specify):
25. NPI #: *
26. Tax ID #:
27. Practice Name:
28. Practice Address:
29. City:
30. State:
31. Zip Code:
32. Practice Office Contact Title:
32(a). First Name *
Last Name *

Last Name
32(b). Office Phone: 32(b). Office Phone: * - ### - ### ####
32(c). Cell Phone: 32(c). Cell Phone: - ### - ### ####
32(d). Contact Email: *
32(e). Fax #: 32(e). Fax #: - ### - ### ####
32(f). Preferred method of contact (select one):{{Prescriber Preferred contact method}} *

32(f). Preferred method of contact (select one):{{Prescriber Preferred contact method}} Office Phone Cell Phone Email Fax
32(g). OK to text Cell Phone (select one):

32(g). OK to text Cell Phone (select one): Yes No
Patient Clinical Information
33. Diagnosis (select one):{{Diagnosis}} *

33. Diagnosis (select one):{{Diagnosis}} Z94.0 Kidney Transplant Status (ICD-10) Other (specify) Other (specify)
34. Date of Transplant: 34. Date of Transplant: * / MM / DD YYYY
35. Did Medicare pay for the transplant surgery (select one)? *

35. Did Medicare pay for the transplant surgery (select one)? Yes No
36. Estimated total daily dose (in milligrams) of ENVARSUS XR® (tacrolimus extended release tablets): *
37. Has a 30-day Voucher of Envarsus XR® (tacrolimus extended-release tablets) been provided to the patient? (select one)

37. Has a 30-day Voucher of Envarsus XR® (tacrolimus extended-release tablets) been provided to the patient? (select one) Yes No
37(a). Date voucher was provided: 37(a). Date voucher was provided: / MM / DD YYYY
HEALTHCARE PROVIDER CERTIFICATION
By providing my signature below, I acknowledge and certify that I have received authorization from the patient applicant to release certain patient applicant information (provided herein) to Veloxis Pharmaceuticals and its service providers, agents, and administrators (collectively, the “Companies”) to assist the patient applicant in obtaining access to ENVARSUS XR® (tacrolimus extended-release tablets). The Veloxis Transplant Support (“VTS”) program may use and disclose the patient applicant information as necessary to enroll my patient in the VTS program should the patient applicant meet the eligibility criteria. I understand that I am under no obligation to prescribe ENVARSUS XR® and that I have not received nor will receive any benefit from Veloxis for prescribing a Veloxis product. I certify that I have prescribed ENVARSUS XR® for the patient for its FDA approved use based on my independent medical judgment that ENVARSUS XR® is medically necessary for the patient and that all information provided on the form is accurate. I attest that I am not on the HHS/OIG list of Excluded Individuals.
Prescriber's Name{{Prescriber name}} *
Prescriber's Signature: Draw your signature into the box below. *

Clear
Only the prescriber is allowed to sign
Date of Signature:{{Date of Prescriber Signature}} Date of Signature:{{Date of Prescriber Signature}} * / MM / DD YYYY
This form does not constitute a valid prescription. If your patient is approved, the filling specialty pharmacy will reach out to you to obtain a valid prescription.
Is the patient currently available to authorize enrollment into Veloxis Transplant Support Services? *

Is the patient currently available to authorize enrollment into Veloxis Transplant Support Services? Yes No
Patient Financial Information (optional unless applying for patient assistance)

Note: This section is required for patients requesting to enroll in the Patient Assistance Program in order to verify eligibility.
38. Total Annual Household Income: * $ Dollars . Cents
39. Sources of Income: (check all that apply)

39. Sources of Income: (check all that apply) Salary Wages Social Security Income (SS, SSI, SSDI) Unemployment compensation Pension/Retirement Veterans Benefits Workers' Compensation Alimony/Child Support Other: Other:
40. Total number of people in household dependent on household income (including Patient): *
Proof of Income:
Instead of providing proof of income documentation, you have the option to consent to an electronic financial screening process to verify household income in the section immediately below.
Note: Proof of household income documentation will be required to determine eligibility for the Veloxis Transplant Support (VTS) Patient Assistance Program (PAP). Acceptable forms of documentation to provide proof of household income reported in this Section include the most recent copy of US federal tax return, Social Security income statements, the two most recent pay stubs, and unemployment or disability statements etc.
Please provide proof of household income. Include one or more of the following documents to provide proof of all income numbers reported above.
PATIENT AUTHORIZATION FOR ELECTRONIC INCOME VERIFICATION (Optional but may reduce enrollment review time)
By providing my signature below, I, the patient applicant, understand that I am providing “written instructions” to Veloxis Pharmaceuticals and its service providers, agents, and administrators (collectively, the “Companies”) under the Fair Credit Reporting Act, authorizing the Companies to obtain information from my credit profile or other information from Experian Health. I authorize the Companies to use and disclose my information solely for the purpose of determining my eligibility to enroll and participate in the Veloxis Transplant Support (VTS) program. I also agree to provide additional financial documentation in a timely manner, if requested. I understand that I must affirmatively agree to all the terms in this authorization in order to proceed in this optional electronic financial screening process. I understand that I am entitled to a copy of this authorization upon request. I understand that I may cancel this authorization at any time by mailing a letter requesting such cancellation to patientsupport@veloxis.com or by calling 1-844-835-6947, but that cancellation shall not apply to any information already used or disclosed through this authorization before the VTS program receive notice of my cancellation.
I agree to electronic income verification (above): *

I agree to electronic income verification (above): Yes No
Patient's or Patient Representatives' Printed Name Patient's or Patient Representatives' Printed Name First Last
Relationship to Patient

Relationship to Patient Self Legal guardian Caregiver
Patient's or Patient Representatives' Signature *

Clear
PATIENT AUTHORIZATION FOR ELECTRONIC INCOME VERIFICATION
Date of Signature Date of Signature * / MM / DD YYYY
PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PATIENT’S PERSONAL HEALTH INFORMATION
By providing my signature below, I, the patient applicant, authorize my healthcare providers, pharmacies, insurance providers, and payers to use, share, and disclose my personal and health information, including information about my insurance benefits, prescriptions, medical condition and history, adherence to my treatment, my general health, and my sensitive health (e.g. communicable diseases (HIV, hepatitis), drug/alcohol abuse, mental health, genetic testing, etc.), (collectively, “Personal Information”) with Veloxis Pharmaceuticals and its service providers, agents, and administrators (collectively, the “Companies”) to: (1) establish my benefit eligibility; (2) provide support services, including facilitating the provision of Veloxis Pharmaceuticals medication to me; and (3) contact me to evaluate therapy and the effectiveness of the VTS program. I understand that once my Personal Information has been disclosed to the Companies, it may no longer be protected by federal privacy law and applicable state laws. I understand that any entity authorized to support the VTS program and any specialty pharmacies providing support to me in connection with the VTS program may receive remuneration from Veloxis Pharmaceuticals. I understand that I do not need to sign this authorization in order to receive healthcare treatment from my healthcare provider(s), insurance benefits, or enrollment in a health plan. However, I understand that if refuse to sign this authorization, I will not be eligible to participant in the VTS program if I meet the eligibility criteria. I understand that if I give my authorization, I may revoke my authorization at any time by sending a notice of revocation to patientsupport@veloxis.com or by calling 1-844-835-6947. I understand that revoking this authorization will end my participation in the VTS program. I understand that my revocation shall not apply to any of my Personal Information that has already been used or disclosed through this authorization before the VTS program received notice of my revocation. I understand my authorizing signature will remain in effect until I am no longer eligible to participate in the VTS program, or Veloxis terminates the VTS program, or the maximum period permitted under state law, if shorter.
Patient's or Patient Representatives' Printed Name Patient's or Patient Representatives' Printed Name First Last
Relationship to Patient

Relationship to Patient Self Legal guardian Caregiver
Patient's or Patient Representatives' Signature *

Clear
PATIENT AUTHORIZATION FOR PHI DISCLOSURE
Date of Signature Date of Signature * / MM / DD YYYY
PATIENT ATTESTATION OF NO INSURANCE COVERAGE (if applicable)
By providing my signature below, I, the patient applicant, attest and certify that I have no health insurance coverage.
Patient's or Patient Representatives' Printed Name Patient's or Patient Representatives' Printed Name First Last
Relationship to Patient

Relationship to Patient Self Legal guardian Caregiver
Patient's or Patient Representatives' Signature

Clear
Patient attestation of no insurance coverage (if applicable)
Date of Signature Date of Signature * / MM / DD YYYY
PATIENT DECLARATION
By providing my signature below, I, the patient applicant, verify that the information provided on this enrollment form is current, complete, and accurate. I understand that such information will be reviewed and relied upon to determine my eligibility for enrollment in the Veloxis Transplant Support (“VTS”) program. I understand that completing this enrollment form does not guarantee that I will qualify for the VTS program. I understand that the VTS program may request additional documentation from me to verify my financial or insurance information, and that any assistance in the form of free medication is contingent upon my ability to meet the VTS program eligibility criteria. I understand Veloxis Pharmaceuticals reserves the right at any time and without notice to modify the enrollment form, modify or discontinue the VTS program and its eligibility criteria, or terminate my enrollment in the VTS program. I agree to notify and shall be responsible for notifying the VTS program if my financial information or insurance coverage changes or if I no longer meet the eligibility criteria for the VTS program. I agree that I will not seek reimbursement or credit from, or submit a claim for Veloxis Pharmaceuticals medication(s) provided through the VTS program to any insurance provider, payer, health plan, or government program, including Medicare Part D Plans, or seek to have Veloxis Pharmaceutical medication(s) or any cost associated with it counted as part of my out-of-pocket cost for prescription drugs. I agree I will notify my insurance provider of my receipt of Veloxis Pharmaceuticals medication(s) provided through the VTS program. I understand and agree that if I am enrolled in a Medicare Part D Plan and eligible for the VTS program, the Companies will notify my Part D Plan of my enrollment in the VTS program. I understand that any Veloxis Pharmaceuticals medication supplied by the VTS program shall not be sold, traded or transferred.
Patient's or Patient Representatives' Printed Name Patient's or Patient Representatives' Printed Name First Last
Relationship to Patient *

Relationship to Patient Self Legal guardian Caregiver
Patient's or Patient Representatives' Signature *

Clear
Patient Declaration
Date of Signature Date of Signature * / MM / DD YYYY
PATIENT TELEPHONE CONSUMER PROTECTION ACT CONSENT (optional)
By providing my signature below, I, the patient applicant, consent to receive enrollment status updates from VTS via telephone call and/or text message. Message and data rates may apply. The number of messages varies based on VTS program selection. Text STOP to cancel or opt out. I understand my consent is not required or a condition of participation in the VTS program.
Patient or Patient's Representatives' Printed Name Patient or Patient's Representatives' Printed Name First Last
Relationship to Patient

Relationship to Patient Self Legal guardian Caregiver
Patient Signature:

Clear
Draw your signature into the box to the left
Date of Signature Date of Signature / MM / DD YYYY
Other Supporting Documents:

Attach Files
Please click submit to begin the PAP Enrollment Process for your patient. Thank you from your Veloxis Transplant Support Team!

If you have any questions please call us at 1-844-VELOXIS (835-6947).
©️2022 Veloxis Pharmaceuticals, Inc. ENVARSUS XR is a registered trademark of Veloxis Pharmaceuticals, Inc.
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Veloxis Transplant Support Enrollment Form

Enrolling in Veloxis Transplant Support

Patient Assistance Program Details

Download Enrollment Form (PDF)

Veloxis Transplant Support Prescription Form

Designation of Agency Form

Patient Contact Information

Patient Insurance Information

19. Primary Insurance

Healthcare Provider Information

Patient Clinical Information

HEALTHCARE PROVIDER CERTIFICATION

Patient Financial Information (optional unless applying for patient assistance)

Please click submit to begin the PAP Enrollment Process for your patient. Thank you from your Veloxis Transplant Support Team! If you have any questions please call us at 1-844-VELOXIS (835-6947).

Please click submit to begin the PAP Enrollment Process for your patient. Thank you from your Veloxis Transplant Support Team!

If you have any questions please call us at 1-844-VELOXIS (835-6947).