XERMELO® Connect Referral Form

About XERMELO^® Connect

XERMELO Connect is a comprehensive patient support program designed to help eligible patients access XERMELO^® (telotristat ethyl) and stay on therapy. The program offers benefits counseling, prior authorization support, co-pay assistance for commercially insured patients, and connection to additional resources for those who qualify.

How to Enroll Your Patient

Complete the form below to refer your patient to the XERMELO Connect program. A program representative will contact the patient within 2 business days to discuss eligibility and next steps. All required fields are marked with an asterisk (*).

Section 1 — Provide your practice information as the referring health care provider.
Section 2 — Enter the treating physician's information if different from the referring provider.
Section 3 — Enter the patient's demographic and contact information.

For assistance completing this form, call 1-844-XERMELO (1-844-937-6356), Monday–Friday, 8 AM–8 PM ET, or fax the completed form to 1-855-215-5318.

Referring
Health Care
Provider

*Name (First, Last)

Site Name

*Street Address

*City

*State

*ZIP Code

*Telephone

*Fax

Office Contact Name

Treating
Physician Health
Care Provider

*Name (First, Last)

Site Name

*Street Address

*City

*State

*ZIP Code

*Telephone

*Fax

Office Contact Name

Patient
Information

*Name (First, Middle Initial, Last)

Sex

Male Female

*Date of Birth

*Email Address

*Street Address

*City

*State

*ZIP Code

Home Telephone

*Mobile Telephone

Legal Representative / Caregiver Name (First, Last)

Relationship to Patient

Caregiver Telephone

Xermelo Connect Referral Form

About XERMELO® Connect

How to Enroll Your Patient

Validation Error

Referral Submitted!

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About XERMELO^® Connect