Download the ACT Program Enrollment Form
English
[PDF: 1MB, 3 pages]
To meet your unique needs, there are 3 ways to start the ACT enrollment process: by phone, fax, or mail.
Phone
Simply call 1-866-EMEND-Rx (1-866-363-6379) and a Reimbursement Specialist will begin the application process.
Fax
- Fill out and sign Section 1 of the application available above. Remember, the application must be completely filled out and signed by both you and your doctor. Please understand that incomplete or incorrectly completed applications will slow down the processing of your request.
- Have your doctor fill out Section 2 and Section 3. For your doctor’s convenience, Section 3 is your prescription. There is no need to obtain a separate prescription form.
- To ensure shipment of EMEND to qualified patients within 48 to 72 hours, fax completed form to 1-866-EMEND-Tx
(1-866-363-6389).
When faxing the completed application, promptly mail the signed original application to the ACT address provided below. Signed original applications must be received for all patients who receive EMEND through the Patient Assistance Program. Product will not be delayed to qualified patients for the first shipment; however, subsequent refill shipments will not be shipped until the original signed application has been received.
If you choose to mail the application, once you have made sure the application is complete, mail to:
- ACT
- PO Box 18979
- Louisville, KY 40261-0979
Remember, mailing is the slowest method of application, and product will not be shipped until 48 to 72 hours after your completed application has been received.
