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H.P. Acthar Gel

1 of 4 H.P. Acthar ® Gel HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to …

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H.P. Acthar Gel

www.acthar.com

1 of 4 H.P. Acthar ® Gel HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use H.P. Acthar® Gel safely and effectively.

  Information, Prescribing, Prescribing information

Acthar Start Form FAX: 1-877-937-2284 Please …

www.acthar.com

1 1. PATIENT INFORMATION Patient has been notified of referral YES NO PATIENT FIRST NAME PATIENT MIDDLE INITIAL PATIENT LAST NAME DATE OF BIRTH GENDER HOME ADDRESS CITY STATE ZIP

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