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 use H.P. Acthar® Gel safely and effectively.
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Acthar Start Form FAX: 1-877-937-2284 Please …
www.acthar.com1 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
H.P. Acthar Gel
www.acthar.com1 of 4 H.P. Acthar ® Gel HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to …
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