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)

Prescribing Information

Sample coding for Evrysdi