Please click here for any questions on CRYSVITA® (burosumab-twza) and to be transferred to Kyowa Kirin Cares website.
GENGLYCOS Ultracare Enrollment Form
1
PATIENT INFORMATION: Remember to choose your preferred contact method
First, Middle, Last Name *
Gender Assigned at Birth MaleFemalePreferred Pronouns
DOB (MM/DD/YYYY) *
Last 4 digits of Social Security #
Street Address *
City *
State *
ZIP *
Home Phone
Work
Mobile *
Best Time to Contact MorningAfternoonEvening
Preferred Language
Email *
Caregiver Name (First and Last)
Relationship to Patient
Caregiver Phone
Patient weight * kg
Date weight taken *
(Final patient weight must be obtained in a medical office within 11-15 calendar days of the scheduled infusion date.)
2
REFERRING PHYSICIAN INFORMATION:
First and Last Name *
City
Office Phone *
Fax
Office Contact Name/Title *
Office Contact Phone *
State License #
NPI # *
Tax ID # *
3
QUALIFIED TREATMENT CENTER (QTC) INFORMATION
QTC is same as referring physician information*
I would like assistance from UltraCare to help identify a QTC*
QTC site name
Address
State
ZIP
QTC site NPI
QTC contact
Phone
Email
4
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)
5
PRIMARY DIAGNOSIS ICD-10-CM CODE
E74.01 Glycogen Storage Disease Type Ia (GSDIa)*
Other:
6
LAB RESULTS DOCUMENTATION
The following test may be required by the insurance provider.
AAV8 Antibody Test: Ordered Completed Date:
Your message has been sent successfully.
