Injectafer Savings Program Eligibility Attestation Form

PP-US-IN-0381 10/17 Injectafer Savings Program Eligibility Attestation form I, _____ (Print Name), certify that on _____&_____ (Dates of Service) I received Injectafer (ferric carboxymaltose injection) and met the Eligibility requirements of the Program listed in the terms and conditions below at the time of the injection. I certify that I am over the age of 18 years old. I certify that I am commercially-insured or an uninsured, cash-paying patient. 1. This offer is valid for commercially-insured as well as cash paying patients.

PP-US-IN-0381 10/17 Injectafer Savings Program Eligibility Attestation Form I, _____ (Print Name), certify that on _____&_____

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