If you are a physician enrolling a patient in Genglycos and would like to
provide consent, please click the button below to provide your consent.
HCP Enrollment Form
ULTRACARE ASSISTANCE IN GAINING ACCESS TO:
GENGLYCOS (pariglasgene brecaparvovec-opnr)
UPON ENROLLMENT, AN ULTRACARE GENE THERAPY GUIDE WILL:
- Be an educational resource for your enrolled patient or caregiver
- Contact the patient or caregiver to review insurance coverage and any available support programs
1&2
Get Started
- Fill out patient and referring physician information
- Identify the patient’s weight and the date it was taken
3
SELECT QUALIFIED TREATMENT CENTER (QTC)
- Choose the QTC for the administration of the medication:
- If known, indicate QTC contact information
4
Verify Insurance
- Provide a copy of all the patient’s MEDICAL and PRESCRIPTION cards, front and back
- Indicate if the patient does not have health insurance
(both medical and pharmacy)
5
Primary Diagnosis ICD-10-CM Code
- Indicate the patient’s primary diagnosis information
6
LAB RESULTS DOCUMENTATION
7
Obtain Consent
- At Ultragenyx we value your privacy. The patient’s and/or caregiver’s signature is required to ensure they agree to and understand how Ultragenyx collects and uses information
We’re Here for You
Whether you have questions, need help accessing treatment, or are looking for assistance with your care plan, our dedicated team is here to support you.