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To be completed in full, signed, and dated, then faxed to 833-578-0346

To be completed in full, signed, and dated, then faxed to 833-578-0346-2025

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The document outlines the ONGENTYS® (opicapone) Patient Assistance Program, which provides financial assistance to eligible patients with Parkinson's disease who do not have prescription coverage for ONGENTYS. It details the application process, eligibility requirements, necessary patient and prescriber information, and important safety information regarding the medication. The program aims to support patients in accessing their prescribed treatment while ensuring compliance with HIPAA regulations.

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