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Healthcare Professionals

Use The Following Steps To Submit Your Form

Step 1: Download the Form

Select which language you would like to download the form in.

Step 2: Complete the Form

After downloading the form, fill out all of the information. Below are the documents & information you will need to complete this form:

  • Patient Information
    If applying for Celgene Patient Assistance Program (PAP), additional patient financial documentation would be needed
    (Click here for details)
  • Physician Information
  • Health Insurance Information (If Available)
  • HCP authorization and signature
  • Patient consent and signature

For Fast Track Program enrollment, in addition to the above, also include the following:

  • Prescription
  • Patient’s Celgene REMS authorization number

Step 3: Choose one of these ways to submit your form

Submit Completed Form Online

  • Upload File

  • *Required


or

Fax

Fax the Completed Form to Us at

1-800-822-2496

Email

Email the Completed Form to Us at

REVLIMID® (lenalidomide) and POMALYST® (pomalidomide) are only available through restricted distribution programs.

Please see full Prescribing Information, including Boxed WARNINGS, for REVLIMID®, POMALYST®, IDHIFA® (enasidenib), INREBIC® (fedratinib), and ABRAXANE® for Injectable Suspension (paclitaxel protein-bound particles for injectable suspension) (albumin-bound). Please see full prescribing information for REBLOZYL® (luspatercept-aamt).

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A Patient Support Specialist is Available to Help

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US healthcare professionals only

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The ICD-10-CM Codes provided here are for diagnoses reasonably related to an indication or indications within the product’s approved label and are provided for your reference only. Other codes may be appropriate. Celgene makes no representation that any code is appropriate for a particular patient. Healthcare Professionals must use their independent judgment in selecting Code(s) to accurately reflect the diagnosis of the specific patient.

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Minju
meet Minju
Celgene Patient Support® Specialist
meet Minju
Minju
Minju is the Celgene Patient Support® Specialist for Zip Code .

If this is not your doctor's zip code, click the zip code link above.

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