4 simple steps to enroll
Follow these simple steps to enroll your patients in Stemline ARC, a support program to help eligible patients access and receive treatment with ELZONRIS® (tagraxofusp-erzs) Injection for Intravenous (IV) Use.
Fill out the enrollment form provided to you by a Stemline Therapeutics, Inc. representative or download the form now.
Together with your patient, sign and date all Stemline ARC enrollment form authorizations, certifications, and consent fields.
Work with your patient to confirm and provide all required documentation for benefits investigation, verification, or Stemline Patient Assistance Program support.
Fax completed application and required documentation to 1-833-329-7836.*
Before faxing your application, please use the checklist below to ensure all of the required documentation is included.
Obtain patient certifications and authorizations
Be sure to include the healthcare provider’s state license number
If the patient is requesting financial assistance or Stemline Patient Assistance Program help, please include the patient’s most recent W2, 1099, or other proof of income
Attach a copy of both sides of all patient insurance cards
*Applications and required documentation may also be mailed to:
PO Box 220293
Charlotte, NC 28222