eHIPAA

For questions and Inquiries,
Please call the AccessPlus Program.
Phone Number: 1-844-445-8843
Fax Number: 1-844-501-7161

Hours of Operations:
8:00 AM - 6:30 PM EST
Monday-Friday

Your session has been inactive for a while now and will expire in two minutes, do you want to continue this session?

About This Form

AccessPlus helps to find potential programs for patients to assist with out-of-pocket costs for ILUVIEN^®. In order for AccessPlus to identify potential financial assistance options, we will need your authorization and consent to use your health information called Protected Health Information (PHI) and to share them with your health insurance and other companies that are necessary to support your treatment. This includes, but is not limited to, specialty pharmacies and your physician.

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

I am signing as parent or guardian (personal representative) of the patient.

Contact Information

Email Address

Patient Cell #

555-555-5555

For questions and Inquiries,
Please call the AccessPlus Program.
Phone Number: 1-844-445-8843
Fax Number: 1-844-501-7161

Hours of Operations:
8:00 AM - 6:30 PM EST
Monday-Friday

About This Form

Patient Information

Personal Representative Information

Contact Information