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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 use H.P. Acthar® Gel safely and effectively.
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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 use H.P. Acthar® Gel safely and effectively.
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
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