Select one of the following options
Once you decide UPLIZNA® (inebilizumab-cdon) is right for your patient, it’s easy to start their enrollment in Amgen By Your Side with the Patient Enrollment Form (PEF) and submit it using one of two convenient options. Patient consent will be required.
Online Submission
Simply fill out the form, sign and submit online through DocuSign®.
Offline Submission
Fill out the form, then download, sign and fax the form to 1-833-329-8477 OR email it to UPLIZNAABYS@amgen.com.
Need help? Download our Patient Enrollment Form Guide (PDF)
Once your patient is enrolled, you will receive a comprehensive summary of your patient’s benefits from the Amgen By Your Side team. We will be there to provide support when your patient needs it throughout their treatment journey.