Forms and Documents

MySMA Support for Evrysdi Enrollment Forms

The Evrysdi Start Form includes the Patient Consent Form (page 4), which is to be completed by the patient, and the Prescriber Service Form (page 5), which is to be completed by the health care provider. Both pages must be completed for enrollment.

To download multiple files at once, select the checkbox next to each file you would like to download from the list above then click Download Selected. Documents will be downloaded as a .zip file.

Other Important Documents

Patient Road Map for MySMA Support by Genentech

This guide provides an overview of how MySMA Support may help patients who have been prescribed Evrysdi access their medicine.

 

Considerations for Composing a Sample Letter of Medical Necessity

This guide provides tips to help you draft a letter of medical necessity. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi

Considerations for Composing a Sample Appeal Letter

This guide provides tips to help you draft an appeal letter. A sample letter is also included for your reference. Use the links below to find additional information to enclose in your letter.

FDA approval letter (Follow this link and search by the drug name)

Prescribing Information

Sample coding for Evrysdi