Online Start Form | OXLUMO® (lumasiran)

Help your patients get started on OXLUMO® (lumasiran) by filling out the online Start Form together.

The purpose of this form is to permit Alnylam Assist® participants to receive additional information and support (“Patient Support”) from Alnylam Pharmaceuticals, Inc., its affiliates, representatives, agents, and contractors (“Alnylam”). Alnylam Assist® provides Patient Support to eligible patients who have been prescribed an Alnylam medicine. This includes: (1) providing reimbursement and financial support to eligible patients (such as investigating your patient’s insurance coverage, confirming out-of-pocket costs, and reviewing eligibility for financial assistance); (2) working with you and your provider to fill your prescription; and (3) providing you with disease and medication-related educational resources and communications; and (4) contacting you to participate in disease and medication-related market research panels or surveys. Your authorization in this form will relate to information and support with respect to any Alnylam medicine you have been prescribed or may be prescribed in the future.

PLEASE NOTE: Consent via electronic signature is mandatory for submission of the form. Forms must be submitted once started, as progress will not be saved. The online Start Form below should only be used if you and the patient are filling it out together currently. If patient is not present, complete a hard copy of the Start Form and fax to 1-833-256-2747 and an Alnylam Case Manager will follow up to obtain patient consent.

Current Patient Information
Insurance Information
Patient Authorization
Prescriber Information
OXLUMO® (lumasiran) Prescription
Confirm & Submit

Patient Information

* Indicates required field.

First Name

Middle Initial

Last Name

Date of Birth

Email Address

Street Address Line 1

Street Address Line 2 (Apartment, Suite, Unit, Etc)

City

State

Zip Code

Home Phone Number

Preferred phone number

Okay to leave voicemail on home phone number

Mobile Phone Number

Preferred phone number

Okay to leave voicemail on mobile phone number

Alternative Phone Number

Preferred phone number

Okay to leave voicemail on alternative phone number

Caregiver Information (Optional)

First Name

Last Name

Caregiver Email

Relationship to Patient

Caregiver Phone

Okay to leave voicemail

Additional Patient Information

Language Translation?

Yes

If yes, please indicate language:

Alnylam Assist® Online Start Form

Patient Information

Home Phone Number

Mobile Phone Number

Alternative Phone Number

Caregiver Information (Optional)

Additional Patient Information

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Online Start Form