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Enrollment Application for the Novartis Patient Assistance ...

Revised Oct 2018 675629-1018 Enrollment Application for the Novartis Patient Assistance Foundation, Box 52029, Phoenix, AZ 85072-2029 | Phone: 1-800-277-2254 | Fax: 1-855-817-2711 Dear Patient and Health Care Professional (HCP): Thank you for your interest in the Novartis Patient Assistance Foundation, Inc. To be eligible, a Patient must: Be a resident Meet the income requirements Have limited or no prescription coverageNovartis Patient Assistance Foundation, following products are available:AFINITOR (everolimus) tabletsAFINITOR DISPERZ (everolimus tablets for oral suspension)ARRANON (nelarabine)ARZERRA (ofatumumab)AZOPT (brinzolamide suspension)CIPRODEX * (ciprofloxacin and dexamethasone) COARTEM (artemether and lumefantrine) COSENTYX (secukinumab)DUREZOL (difluprednate emulsion) ENTRESTO (sacubitril/valsartan)EXJADE (deferasirox)EXTAVIA (Interferon beta-1b)FARYDAK (panobinostat) capsulesFOCALIN XR (dexmethylphenidate hydrochloride)GILENYA (fingolimod)GLATOPA (glatiramer acetate i)

administered by NPAF may change or end at any time without prior notification. I understand that I may receive a copy of this authorization. I agree to be contacted by NPAF by mail, e-mail, telephone calls, and text messages at the number(s) and address(es) provided on the NPAF application for all purposes described in this Patient Authorization.

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Novartis Patient assistance Foundation Application

www.novartis.us

• Patient Section 5: We need you to read the Patient Authorization page to allow us to process your application, communicate with you and manage your enrollment. Please read, sign and date at the bottom of the Patient Application. Lastly, work with your health care provider (HCP) to complete his/her sections of the application. If you

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MAYZENT. treatment and if there is any change in vision ...

www.novartis.us

Test patients for antibodies to varicella zoster virus (VZV) before initiating MAYZENT; VZV vaccination of antibody-negative patients is recommended prior to commencing treatment with MAYZENT [see Warnings and Precautions (5.1)]. Liver Function Tests

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HIGHLIGHTS OF PRESCRIBING INFORMATION CAR-positive …

www.novartis.us

See full prescribing information for complete boxed warning. • Cytokine Release Syndrome (CRS), including fatal or life-threatening reactions, occurred in patients receiving KYMRIAH. Do not administer KYMRIAH to patients with active infection or inflammatory disorders. Treat severe or life-threatening CRS with

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ADAKVEO. ADAKVEO HIGHLIGHTS OF PRESCRIBING …

www.novartis.us

Pregnancy: May cause fetal harm. (See 17 for PATIENT COUNSELING INFORMATION and FDA-8.1) approved patient labeling. Revised: 7/2021 FULL PRESCRIBING INFORMATION: CONTENTS* 1 INDICATIONS AND USAGE 2 DOSAGE AND ADMINISTRATION 2.1 Recommended Dosage 2.2 Preparation and Administration 2.3 Management of Infusion …

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Instructions - Novartis United States of America

www.novartis.us

I consent to receive marketing calls and texts from and on behalf of NPAF, made with an auto dialer or prerecorded voice, at the phone number(s) provided. I understand that my consent is not required or a condition of purchase. Number of messages will vary based on your program selections. Message and data rates may apply.

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HIGHLIGHTS OF PRESCRIBING INFORMATION These …

www.novartis.us

acute lymphoblastic leukemia (Ph+ ALL) in combination with chemotherapy. (1.4) ... Reports of motor vehicle accidents have been received in patients receiving Gleevec. Caution patients about driving a car or operating machinery. (5.13) Renal Toxicity. A decline in renal function may occur in patients receiving

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HIGHLIGHTS OF PRESCRIBING INFORMATION These …

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Pancreatitis and Elevated Serum Lipase: Monitor serum lipase; if elevations are accompanied by abdominal symptoms, interrupt doses and consider appropriate diagnostics to exclude pancreatitis. (5.5) Hepatotoxicity: Monitor hepatic function tests monthly or …

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prescribing information for AFINITOR/AFINITOR DISPERZ ...

www.novartis.us

with sunitinib or sorafenib. (1.3) Adults with renal angiomyolipoma and tuberous sclerosis complex (TSC), not requiring immediate surgery. (1.4) AFINITOR and AFINITOR DISPERZ are kinase inhibitors indicated for the treatment of adult and …

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COSENTYX (secukinumab) injection, for subcutaneous use o ...

www.novartis.us

COSENTYX is indicated for the treatment of adult patients with active non-radiographic axial spondyloarthritis (nr-axSpA) with objective signs of inflammation. 1.5 Enthesitis-Related Arthritis COSENTYX is indicated for the treatment of active enthesitis-related arthritis (ERA) in patients 4 years of age and older.

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HIGHLIGHTS OF PRESCRIBING INFORMATION may worsen …

www.novartis.us

2.8 Calcium and Vitamin D Supplementation Instruct patients being treatedfor Paget’s disease of bone on the importance of calcium and vitamin D supplementation in maintaining serum calcium levels, and on the symptoms of hypocalcemia. All patients should take

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www.cms.gov

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Medicare Enrollment Application - HHS.gov

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Clinics and group practices can apply for enrollment in the Medicare program or make a change in their enrollment information using either: •The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or •The paper enrollment application process (e.g., CMS 855B).

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Tips to Facilitate the Medicare Enrollment Process

www.cms.gov

change in their Medicare enrollment, or view their Medicare enrollment information on file with Medicare. Internet-based PECOS is a scenario-driven application process with front-end editing capabilities and built-in help screens. The scenario-driven application process will ensure that

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Texas Hazlewood Act Exemption Application For Continued ...

www.tvc.texas.gov

students subsequent to initial enrollment at the school in which the student is currently and consistently enrolled. If a break in enrollment or change of school occurs then the complete Hazlewood Exemption application must be completed.

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To log into WAVE - Veterans Affairs

benefits.va.gov

Feb 27, 2015 · Check Pending Documents – Allows you to see if the Regional Processing Office has a claim waiting to be processed. Email Address Settings – Allows you to change your email address and email preference. Change Password – Allows you to change your password. Exit WAVE – Exits the web site, and takes you back to the GI Bill page. The Benefit Status and Verify Monthly Enrollment Status ...

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Understanding Special Enrollment Periods

marketplace.cms.gov

Change in primary place of living You (or anyone in your household) had a change in your primary place of living and gain access to new Marketplace health plans. Household moves that qualify you for a Special Enrollment Period include: nMoving to a new home in a new ZIP code or county nMoving to the U.S. from a foreign country or U.S. territory

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