FREE TRIAL OFFER FOR NEW PATIENTS INITIATING THERAPY

Eligible enrolled patients with prescription can receive
a free 30-day supply of CALQUENCE.

Patient Eligibility

Please answer the following questions.

*Required field.

*Was CALQUENCE prescribed?

Yes

Please select Yes or No

*Is this the patient’s first use of CALQUENCE?

Yes

Please select Yes or No

*Is the patient at least 18 years old?

Yes

Please select Yes or No

*Is the patient a current resident of the United States or Puerto Rico?

Yes

Please select Yes or No

Based on the information provided, this patient is not eligible for this offer. AstraZeneca is committed to helping patients get access to their medication. If there are concerns about paying for the patient’s medication, there may be additional support available. To learn more about Access 360’s support offerings, please visit myaccess360.com or call 1-844-ASK-A360 (1-844-275-2360).

This description of the Access 360 program is for informational purposes only. Access 360 does not file claims or appeals on behalf of health care professionals or patients and makes no representation or guarantee concerning reimbursement or coverage for any service or item.

Attestation

By agreeing to these terms, I certify that (1) I have received the necessary authorization to release the information included on this form and other related Protected Health Information (as defined by HIPAA) to AstraZeneca, including employees, contractors, or affiliates of AstraZeneca, and health care plans for programs, dispensing pharmacy(ies) or other entities, for the purposes of treatment and payment support, and (2) I have obtained any necessary authorization to allow AstraZeneca to contact the patient, if not included with this submission to obtain a signed AstraZeneca Patient Authorization.

I agree

You must select “I agree” to continue

Patient Information

Please provide the following information.

*Required field.

*Patient First Name

Please enter Patient First Name

Middle Initial

*Patient Last Name

Please enter Patient Last Name

Suffix

*Date of Birth

Please enter Date of Birth

*Gender

Male

Female

Other

Please select Gender

*Home Address 1

Please enter Home Address

Home Address 2

*City

Please enter City

*State

Please select State

*ZIP

Please enter ZIP

*Preferred method of contact (please specify)

Cell Phone

Home Phone

Alternative Phone

Email Address

Please enter Preferred method of contact

Provider Information

Please provide the following information.

*Required field.

*Provider First Name

Please enter Provider First Name

*Provider Last Name

Please enter Provider Last Name

Provider NPI #

Please enter Provider NPI

Provider Address 1

Provider Address 2

City

State

ZIP

Provider Office Phone Number

Insurance Information

Insurance Plan Type

Commercial Insurance

Medicare

Medicaid

Other Insurance

Patient Eligibility for this Free Trial Offer is not based on patient insurance status.

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FREE TRIAL OFFER FOR NEW PATIENTS INITIATING THERAPY

Eligible enrolled patients with prescription can receive a free 30-day supply of CALQUENCE.

Patient Eligibility

Attestation

Patient Information

Provider Information

Insurance Information

Contact Us

Eligible enrolled patients with prescription can receive
a free 30-day supply of CALQUENCE.