Access 360 General Patient Authorization Form (PAF)

Get started today

Access 360 General Patient Authorization Form (PAF)

Access 360 Patient Authorization Form (PAF)

Fill this form out to allow Access 360 to provide assistance for your KOSELUGO prescription. Available in English and Spanish. The Access 360 General Patient Authorization Form must be signed for you to utilize Access 360 support.

DOWNLOAD IN ENGLISH DOWNLOAD IN SPANISH

Click here to fill out the form online.

TRADENAME Affordability Brochure

KOSELUGO Patient Overview Brochure

This brochure provides information about the KOSELUGO Support program for patients.