Fayuvi HCP Enrollement form

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Fayuvi Ultracare Enrollment Form

Patient Enrollment Form

Toll-free line: 888-756-8657 Fax: 415-723-7474 Address: 5000 Marina Boulevard, Brisbane, CA 94005

PATIENT INFORMATION:

First, Middle, Last Name *

Gender
MaleFemale

DOB (MM/DD/YYYY) *

Last 4 digits of Social Security #

Street Address *

City *

State *

ZIP *

Home Phone

Work

Mobile *

Best Time to Contact

Preferred Language

Email *

Caregiver Name (First and Last)

Relationship to Patient

Caregiver Phone

Patient weight *

kg

Date weight taken *

REFERRING PHYSICIAN INFORMATION:

First and Last Name *

Street Address *

City *

State *

ZIP *

Office Phone *

Fax

Email *

Office Contact Name/Title *

Office Contact Phone *

State License #

NPI # *

Tax ID # *

QUALIFIED TREATMENT CENTER (QTC) INFORMATION

QTC is the same as the site of care for referring physician listed above*

I would like assistance from UltraCare to help identify a QTC*

I would like to refer my patient to the QTC listed below*

QTC site name

Address

City

State

ZIP

QTC site NPI

QTC contact

Phone

Fax

INSURANCE INFORMATION: Be sure to provide copies of patient’s MEDICAL and PRESCRIPTION cards

Patient does not have health insurance

Patient demographic sheet provided

Provide copies of all medical and prescription cards—front and back (primary and secondary, supplemental coverage)

PRIMARY DIAGNOSIS ICD-10-CM CODE

E76.22 Sanfilippo Mucopolysaccharidosis*
Subtype:

Other:

I attest that I am a licensed healthcare provider submitting this enrollment form on behalf of my patient.*

If you’re having difficulty submitting this form, please reach out to the Ultracare team at 888-756-8657 for assistance.

1-888-756-8657

Cookie Policy

The information on this website should not be used for diagnosing or treating a health problem or disease.

This information is intended for US healthcare professionals only.

MRCP-UGNX-00021 09/2026

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