Forms and Documents for Prograf
We've provided a number of different forms and letters to help you.
Forms for Benefit Verification and Patient Assistance Requests are no longer available on this site. For your convenience Benefit Verification Requests and Patient Assistance Requests can now be submitted conveniently online via Astellas eService
If you don't see a form you need, please contact us at 1-800-477-6472.
- FDA Approval Letter - Heart (PDF - 536 KB)
- FDA Approval Letter - Kidney (PDF - 8.2 MB)
- FDA Approval Letter - Liver (PDF - 8.1 MB)
- Patient Authorization to Disclose Health Information (HIPAA) (PDF - 123 KB)
- Sample Letter of Denial Appeal (PDF - 199 KB)
- Sample Letter of Medical Necessity (PDF - 164 KB)
- Sample Letter of Medicare Carrier Advisory Letter (PDF - 146 KB)
- ASPN Intake Form (PDF - 68 KB)
- Medication Exception Request Form (PDF - 51 KB)
- Second Quarter 2012 (4/1/12 - 6/30/12) (PDF - 307 KB)
- First Quarter 2012 (3/1/12 - 3/31/12) (PDF - 689 KB)
- Medicaid Medication Appeal Request Form (PDF - 48 KB)
Some forms and documents provided on this Web site are not the property of Astellas Pharma US, LLC, and may be subject to change.
