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Dupixent enrollment form 2022-2026

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The document is an Enrollment Form for the DUPIXENT MyWay program, which provides support for patients using the medication DUPIXENT (dupilumab) for atopic dermatitis. It includes sections for patient and insurance information, prescriber details, patient authorization for health information disclosure, and consent for text messaging. The form must be completed in full and faxed to the specified number to prevent delays in processing.

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Click ‘Get Form’ to open the dupixent enrollment form 2022 in the editor.
Begin by filling out the 'Patient Information' section. Enter your name, date of birth, sex, and contact details including preferred phone numbers and email address.
In the 'Insurance' section, provide details about your primary insurance. If you have no insurance, select that option and complete Section 6 if applicable.
Next, move to the 'Prescriber' section. Fill in the prescriber's name, NPI number, and prescription details for DUPIXENT.
Complete the 'Patient Certifications' and 'Authorization' sections by reading carefully and signing where indicated. Ensure all required fields are filled out accurately.
Finally, review all entries for accuracy before submitting. Once completed, fax all four pages to the provided number to prevent delays.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What form does DUPIXENT come in?

Dupixent comes in two different dosage forms: a pre-filled syringe or a pre-filled injection pen. Both options are available in 200 mg and 300 mg doses.

How to get a prescription for DUPIXENT?

To get a prescription for Dupixent, youll need to make an appointment with a healthcare professional, such as a dermatologist or an allergist. A dermatologist is a doctor who specializes in diagnosing and treating conditions affecting the hair, skin, and nails.

How can I get DUPIXENT for free?

As Little As $0* Copay With the DUPIXENT MyWay Copay Card, eligible patients with commercial health insurance may pay as little as $0* in copay per fill of DUPIXENT. Terms and conditions apply.

How do I enroll in DUPIXENT My Way?

To enroll or obtain information call 1‑877‑311‑8972 or go to .

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