AGRMT RE - OP SAMPLE PROGRAM FORM FOR ABILIFY MAINTENA WITH OTSUKA AMERICA PHARM.PDF

Certification Form
ATTENTION
This form must be completed and signed before requesting product Starter Program kits.
Date: 05/02/2018
Instructions for submitting Certification Form:
Prescriber listed must sign and date this
form
Fax form to: 1-855-234-6515
KFIS000196-06051523363
Phone: Fax:
This Certification Form is applicable only for:
ABILIFY MAINTENA® (aripiprazole) for extended-release injectable suspension
treatNOW is a program that supplies ABILIFY MAINTENA® (aripiprazole) kits at no cost.
• The treatNOW kits are not for sale, resale, barter or trade and they must not be billed to any third party payer (health care or insurance
program).
• The program is available to qualified, licensed health care practitioners (for example, treating physicians) who, in their independent medical
judgment, determine that immediate onsite treatment of their patient with a diagnosis within the product's approved label is medically warranted.
• The program allows health care practitioners to place an order and then elect to ship treatNOW kits of ABILIFY MAINTENA® (aripiprazole)
either to themself, or to a pharmacy at a health care entity with which the practitioner is affiliated. Retail pharmacies are excluded.
• The program is designed to be in compliance with 21 C.F.R. § 203.
When you ("you" means a health care practitioner or a pharmacy at a health care entity) sign any of the treatNOW forms or documents, you
certify that:
• You have procedures in place that will ensure that the treatNOW kits will not be sold or billed to any third party.
• You are authorized and in good standing to request and/or receive these kits under relevant state and federal laws.
• There is an affiliation between the health care practitioner requesting the treatNOW kits and any health care entity to which shipments of
ABILIFY MAINTENA (aripiprazole) are directed.
• You understand that there are ongoing program requirements you must meet to continue to be eligible to receive treatNOW kits, for example,
returning the Acknowledgement of Contents form in each shipment and re-enrolling every two years. If you don't meet these requirements, your
participation will be paused or terminated.
Prescriber Signature Date
•
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44111 -1.-tt <It'd I 71111 ( For questions regarding the program call 1-(844)-TreatNOW.
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0 2016 Otsuka America Pharmaceutical, Inc., Rockville, MD. All rights reserved. Printed in the USA. August 2016 09US16EBP0334
ONRHA052A 32176004 1