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Enrollment Forms

To begin the enrollment process:

  1. Search by either the product name or the therapy name below.
  2. Print the PDF version of the Enrollment Form.
  3. Fax the completed form, signed by the prescriber, and the fax cover sheet (if provided) back to us at the fax number indicated on the PDF.

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PANTHERx Rare

24 Summit Park Drive | Pittsburgh, PA 15275 USA

Phone: 855.726.8479 (412.246.9858)

Fax: 855.246.3986 (412.787.9400)

Email: pharmacist@pantherxrare.com

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PANTHERx RARE PHARMACY, "REINVENTING PHARMACY, REVOLUTIONIZING SPECIALTY, REDEFINING CARE", and THE RARE DISEASE SP are registered service marks of PANTHERx Rare, LLC.

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