Ferring Product Claim Claim Form

Ferring Product Claim Form

To ensure timely processing, please complete and submit this form with all required information within 30 days of the event related to Adstiladrin.

Healthcare Provider/ Site of Care Information

First Name

Last Name

Prescriber NPI #

Office/Clinic/Institution Name

City

State

Office Phone

Office Fax

Office Email

Office Contact Name

Contact Phone

Contact Email

PO Number

Enter Ferring Access Support Hub ID or Patient Year of Birth

Ferring Access Support Hub ID

Patient Year of Birth

Speciality Distributor Purchased From or Speciality Pharmacy Dispensed From

Besse Medical (Cencora)

Optum Frontier Specialty Distributor

Optum Frontier Pharmacy

Transition Pharmacy

Other

Date of Original Order

Specification of Product Claim

Please select one of the following options:

Patient expelled ADSTILADRIN from the bladder within 10 minutes of administration.

For more information please see the ADSTILADRIN Limited Warranty Program

Product was prepared and not administered to patient due to unforeseen circumstances.

For more information please see the ADSTILADRIN Product Replacement Policy

(First Name) (Last Name) certifies that a claim for commercial OR government insurance for reimbursement will not be pursued, nor will reimbursement for a cash payment, including in the form of a patient copayment or deductible be initiated, for both the original Product and the replacement Product.

Ferring reserves all rights and matters regarding their programs and may extend, shorten, or modify the term of the Replacement Program, the Warranty Program or both at its sole discretion.