Forms and Documents
To contact MySMA Support call (833) 387-9734 (Monday–Friday, 9 a.m.
to 8 p.m. ET).
Quickly Enroll in MySMA Support brochure
The Quickly Enroll in MySMA Support brochure provides a step-by-step
overview of using E-Submit (also known as Quick Enroll) to enroll
patients in MySMA Support.
Enrolling Patients in MySMA Support by Genentech brochure
The Enrolling Patients in MySMA Support brochure provides tips for
completing the Evrysdi Start Form and includes important information
about the MySMA Support team.
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.
Sample Letter of Medical Necessity or Appeal Template
This sample letter provides examples of information that may be
required when completing a letter of medical necessity or an appeal
letter. You may use this template as a guide to help you draft a
letter of medical necessity or an appeal letter.
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)
