Before you can get your patients started with Adempas, you must first fill out the enrollment forms found below. Within the Adempas Prescription form, you can also enroll your patients in the Aim Patient Support Program for support throughout their treatment journey.
- For FEMALE patients, please complete and sign the Adempas REMS Patient Enrollment and Consent Form found below, and then make sure to obtain your patient's signature and date. This enrollment form CANNOT be processed without your patient's signature.
- For ALL patients, please complete and sign the Adempas Prescription and Patient Support Program Enrollment Form found below, and then make sure to obtain your patient's signature and date.
- If your patient has no insurance, check "No" and the Aim Support Program Center will evaluate other financial assistance options.
With the Aim Patient Support Program, your patients can take advantage of helpful resources such as 24/7 nursing services and financial assistance. With this optional patient consent, this will allow information to be shared with third parties such as pharmacies, insurance companies, and Bayer. To receive these optional services, all patients should sign and date the necessary sections within the Adempas Prescription and Patient Support Program Enrollment Form.
There are two ways to submit the Adempas Enrollment Forms by utilizing e-signature online or printing and sending to the Aim Support Program Center.
Enroll Online: A fast and secure method for Aim to receive enrollment from prescribers and patients. Simply fill out the forms online and sign electronically. Please note, the e-signature process requires both prescriber and patient email addresses. Start the online enrollment process here. If you are new to the e-signature process, please click here for a tutorial.
Other Ways to Enroll: Submit your forms to the Hub via fax (1-855-662-5200), email, or the physician portal.
Download the Adempas Prescription and Patient Support Program Enrollment Form
Please click here to download the Spanish version.
Front and Back of Patient’s Insurance Card