HOW TO COMPLETE
THE PRESCRIPTION
START FORM

How to complete the Prescription Start Form

  1. Download, print, and complete your Prescription Start Form with the help of your healthcare provider. This document serves as a prescription and a consent to receive support from PTC Cares™ and PTC products, including EMFLAZA®
  2. Sign the patient/caregiver consent section of the Prescription Start Form
  3. After it’s finished, your healthcare provider will submit the completed Prescription Start Form to PTC Cares

the Prescription Start Form INSTRUCTIONS

For Patients and Caregivers

STEP 1

Complete your insurance information on the patient side of the form

STEP 2

Sign at the bottom of the form to prevent delays in processing the prescription

Have your CHILD‘s physician complete this side of the form

STEP 1

Sign both prescriptions (Primary and Bridge) in the Prescription Information section of the form. This will ensure your patient has ongoing access to EMFLAZA

STEP 2

Sign at the bottom of the form where it says “Prescriber Authorization Signature”

STEP 3

PTC Cares may also need additional documentation, such as:

  • Statement of medical necessity
  • ICD-10 code
  • Chart notes or dosage changes
  • Patient’s prior medical history of taking prednisone

For information about PTC Cares

Call 1-844-4PTC-CARES (1-844-478-2227)
Monday—Friday 8 am—8 pm, ET