Forms for patients and healthcare professionals

To get started, complete the Patient Application Form. For prescription products, the physician must complete the Product Prescription Form or submit an original script. For physician-administered medications that are covered under the patients medical benefit (versus pharmacy benefit), providers administer Amgen product from their existing commercial stock to qualifying Foundation patients and then order replacement for this product from the Foundation. For IMLYGICTM the physican must complete the IMLYGICTM Form to request shipment prior to administration.

Institutions that have enrolled as Individual Patient Assistance Program (IPAP) facilities may use the IPAP Patient Application to enroll their patients.

Forms revised July 2015.

Once a completed application and any required supporting documents have been received and processed the patient and provider will be notified of the enrollment decision. Missing information or an incomplete application will delay an enrollment decision.

As of July 03, 2015 The Safety Net Foundation will only accept the current version of the Patient Application Form, released on April 03, 2015. If an older version of the application is submitted we will notify you to complete the current form and re-submit.

Patient Applications

Product Prescription Form

Product Replacement Form

IMLYGICTM On-Demand Request Form