Forms and Documents with EASE

EASE Enrollment Form

This form allows you to help request financial assistance or coverage-related information for patients.

The Enrollment Form can also be downloaded, completed, and faxed back to 1-844-901-3273.

Patient Authorization Form

This form is for your patients to authorize the use of their health care information in relation to support with EASE.

Dose Exchange Program

Provides a free 15-tablet supply in the lower dose to help patients who require a dose reduction.^*†