Fill out the form below to enroll with SPACassist, a patient-support program. SPAC will provide frequent communications and tools to help you manage your therapy. In
addition to the information already provided by your health care team, you'll also have access to a registered clinically trained staff who can provide you with information regarding your treatment.
I verify that the information provided in this enrollment form is
current, complete, and accurate. I understand SPAC International reserves the right at any
time, and without notice, to modify or discontinue the SPACassist Program with respect to
any patient (including me), or to modify or discontinue the program entirely.
I authorize the SPACassist Program to use and obtain my protected health information
from my prescribing physician, insurance company, specialty pharmacy and other sources
as deemed necessary to ensure the accuracy and completeness of this enrollment form, to
provide services to me, and to otherwise administer the SPACassist Program.
I acknowledge that I am a legal resident of the United States. I authorize my healthcare
providers, insurance companies, and specialty pharmacies to use and disclose to SPAC
international, the SPACassist Program and their authorized agents and assignees, all
medical records and financial information with respect to my treatment, my eligibility for
assistance, the coordination of my treatment (and the receipt of my medication),
and my participation in the SPACassist Program for the purposes of providing services to
me and otherwise administering the program. I understand that my healthcare providers
and insurance company will not modify my medical treatment, payment for treatment,
insurance enrollment, or eligibility for insurance benefits on my signing of this
authorization. I understand, however, that if I do not sign this authorization, I will not be
eligible to enroll in the SPACassist Program.
If I do not wish to receive information related to my medication (or any related products or
services) or to be contacted occasionally for market research purposes, I may call the
SPACassist Program's phone number (661) 320-4477 during business hours.