Aristada caresupport program co-pay

Oct 11, 2023 · When you choose UnitedHealthcare, you'll find a variety of programs available to help support your health and wellbeing. Learn which programs are included with your plan so you can get the support you need – from caregiver resources to maternity support, wellness rewards to weight loss programs and much more.

10. Co-PAy sAvinGs PRoGRAM inFoRMAtion FoR ELiGiBLE PAtiEnts – CoMPLEtE sECtion iF yoU WoULD LikE ACs to sEnD PREsCRiPtion to PHARMACy WitH CoPAy CARD inFoRMAtion. PAtiEnts sHoULD CoMPLEtE ALL FiELDs on tHis PAGE. QUEstions? CALL 1-866-ARistADA (1-866-274-7823), 9AM–8PM (Et).a Copay Accumulator Program. Deductible is met Copay assistance limit is met Out-of-Pocket maximum is met. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec. Total Insurer collects. Copay Assistance $1,680 $1,680 $1,240 $840 $840 $840 $80 $0 $0 $0 $0 $0 $7,200. $8,550. Remaining Deductible $2,920 $1,240 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 …CO-PAY TERMS AND CONDITIONS. To participate in the YONSA ® Co-Pay Program (“Program”), you must present this card, along with a valid prescription for YONSA ®, to your pharmacist.Patients with commercial health insurance who qualify to participate can pay as little as $0 per month for one YONSA ® prescription. Enrollment is subject to the …The Centers for Medicare and Medicaid Services in both 2020 and 2021 issued a final rule in the Notice of Benefit and Payment Parameters on the issue of copay adjustment programs. Running contrary to recent state action, the rule allows health plans to use copay adjustment programs and defers to state law on their regulation.Take advantage of support services. Find options for financial assistance, nurse support, benefits coverage, and more. Shared Solutions support. 1-800-887-8100. M-F, 8AM to 8PM CT.Highest savings at fill is $1600.00 for ARISTADA 1064 milligram, up to 6 fills per calendar year, with maximum savings up to $7600 per agenda year. Maximum out-of-pocket cost per fill, after Co-pay savings applied, is $10. For ARISTADA INITIO, limit savings is up to $2000.00 total, and Co-pay card may becoming used up to 4 times at calendar year. Co-pay Savings Program for eligible patients with commercial insurance. Patients may pay as low as a $10 co-pay per prescription for ARISTADA INITIO® (aripiprazole lauroxil) and ARISTADA® (aripiprazole lauroxil) …

Aristada Care Support Co-Pay Savings Card For Healthcare Professionals Only: Provided by: Alkermes, Inc. Languages Spoken: . English, Spanish, Vietnamese, Others By Translation ServiceThe Program includes the copay card and Rebate, with a combined annual limit of $18,000. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all ...ARISTADA® (aripiprazole lauroxil) is <covered/not covered>. If you have any questions about this Summary of Benefits or ARISTADA®, please contact ARISTADA Care Support at 866-ARISTADA (866-274-7823) Monday through Friday, 8am – 8pm, Eastern Time. A B F C E D WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSISEfficacy of the 2-month Dose. The efficacy of ARISTADA 441 mg monthly and 882 mg monthly was established in the phase 3 clinical trial. The efficacy of ARISTADA 662 mg monthly, 882 mg every 6 weeks, and 1064 mg every 2 months was established by pharmacokinetic bridging, which demonstrated that these dosing regimens resulted in plasma ...Aristada Care Support Co-Pay Savings Card For Healthcare Professionals Only: Provided by: Alkermes, Inc. Languages Spoken: English, Spanish, Vietnamese, …

Medication Guide at www.ARISTADA.com or call 1-866-ARISTADA. Page 3 of 5 ARISTADA® Provider Network Agreement Alkermes reserves the right to alter or discontinue this program at its discretion. If you wish to remove your organization, practice or any of your sites from this program please notify ARISTADA Care Support at 866 …Your monthly Aristada cost savings if eligible. The Aristada patient assistance program can provide your medication for free. We simply charge $49 per month for each medication to cover the cost of our services. With NiceRx, you will only pay $49 to obtain your Aristada, regardless of the retail price. Software offers co-pay assistance, reimbursement support, and patient assistance related used eligible patients. Patients use Medicare Parts D could be eligible, contact program …Call our AimAlly ™ Support Team at 833-AIMOVIG (833-246-6844), Monday–Friday, 8 am –9 pm et. I have Medicare or Medicaid. 69% of Medicare Aimovig prescriptions cost patients $20 or less per month, 1 and the remaining 31% of Medicare Aimovig prescriptions cost patients an average of $117 per month. 2-5.

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The ARISTADA Provider Network is compiled and published by Alkermes, Inc. as a reference source of demographic and professional information on individual licensed healthcare providers in the United States who have experience in the treatment of schizophrenia. The ARISTADA Provider Network is searchable by zip code or by city and state. Are you tired of paying for expensive word document programs? Do you want to find a free alternative that can meet all your document creation needs? Look no further. In this article, we will introduce you to some of the best free word docum...Program Contact Information; Abilify: Bristol-Myers Squibb. Abilify. 1-800-736-0003 Patient Assistance Foundation. 1-888-922-4543 Assist Savings Program. Aristada: Alkermes: 1-866-274-7823 Aristada Care Support. Brintellix. Takeda: 1-800-830-9159 Help at Hand Patient Assistance Program. Clozapine (generic) Teva Clozapine: 1-800-507-8334 Patient ...Aristada Care Support This program provides brand name medications at no or low cost: Provided by: Alkermes, Inc. TEL: 866-274-7823 FAX: 844-464-7171: Languages Spoken: English, Spanish. Program Website : Patient Assistance Applications: Aristada Care Support Patient Assistance Program Enrollment FormHours of Operation: Monday - Friday 8:30 AM - 6:00 PM EST. Applications for the Bl Cares Patient Assistance Program for OFEV should be faxed to 1-855-297-5907. Visit the Boehringer lngelheim website to download the BI Cares Patient Assistance application form …

Yep the VA will cover it. Some require you to participate in an exercise program called the MOVE program though. My primary care doc stated I need to do the Move program and if the nutritionist recommended the medication then my doc would submit a request for it that may or may not be approved. In the first meeting with my nutritionist in the ...Aristada Care Support This program provides brand name medications at no or low cost: Provided by: Alkermes, Inc. TEL: 866-274-7823 FAX: 844-464-7171: Languages Spoken: English, Spanish. Program Website : Program Applications and Forms: Aristada Care Support Patient Assistance Program Enrollment FormOther Savings & Support Programs. Amneal also offers savings program for select products as listed below: Abiraterone Acetate Co-Pay Card (opens in a new tab); Bexarotene Gel, 1% Co-Pay Card (opens in a new tab); Dimethyl Fumarate DR Savings Card (opens in a new tab); Emtricitabine and Tenofovir Disoproxil Fumarate Co-Pay …Maximum cost at fill is $1600.00 for ARISTADA 1064 mg, up to 6 fills per calendar year, with maximum savings up to $7600 per calendar year. Minimum out-of-pocket cost per fill, after Co-pay assets applied, lives $10. For ARISTADA INITIO, maximum lifetime the up to $2000.00 total, and Co-pay card can shall used up to 4 times per calendar year.Aug 23, 2022 · treatment program. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare’s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage.We understand that the LLS Co-Pay Assistance Program helps to remove some of those barriers. We hear you; we know that lack of funding to cover your co-pays for medical expenses and/or insurance premiums adds to the stress and anxiety brought on by the financial burden of your diagnosis. We know you are struggling, and we are working to …Many pharmaceutical companies and specialty pharmacies have assistance programs that may be able to help patients cope with the financial aspects of a cancer diagnosis. For example, they may provide co-pay assistance to help people who have health insurance pay for the out-of-pocket costs associated with prescription drugs.Interested providers, including retail pharmacies and clinics, may contact ARISTADA Care Support (1-866-274-7823) or Vivitrol2gether SM (1-800-848-4876) to determine if they are eligible to be ...NeedyMeds has free information on medication and healthcare fee savings programs inclusion prescription supports programs and medical plus dentistry hospitals.

With the DUPIXENT MyWay Copay Card, eligible, commercially insured patients may pay as little as $0* copay per fill of DUPIXENT. Eligible patients will receive their cards by email. Program has an annual maximum of $13,000. You may be eligible for the DUPIXENT MyWay Copay Card if you:. Have commercial insurance, including health insurance …

When you’re struggling to make ends meet, it can be difficult to know where to turn for help. One option that many people don’t consider is their local church. Many churches have programs in place that can help you with your bills and other...If you are struggling financially and can't pay to heat your house, you may be in luck. There are many programs, though you must check to see if you qualify. If you need heating oil assistance and use EverSource or National Grid, check out ...When it comes to computer-aided design (CAD) software, there are a variety of options available, ranging from free programs to high-end paid software like SolidWorks. While the allure of free software may be tempting, it’s important to cons...Aripiprazole Lauroxil Pharmacokinetic Profile of This Long-Acting Injectable Antipsychotic in Persons With Schizophrenia. J Clin Psychopharmacol. 2017;37 (3):289-295. 2. Hard M. Population Pharmacokinetic Analysis and Model-Based Simulations of Aripiprazole for a 1-Day Initiation Regimen for the Long-Acting Antipsychotic Aripiprazole Lauroxil.Medication Guide at www.ARISTADA.com or call 1-866-ARISTADA. Page 3 of 5 ARISTADA® Provider Network Agreement Alkermes reserves the right to alter or discontinue this program at its discretion. If you wish to remove your organization, practice or any of your sites from this program please notify ARISTADA Care Support at 866 …May 31, 2022 · The complaint cites a highly revealing SaveonSP training video, which provides crucial context for understanding how copay maximizers really work. (Note that the deck was presented on an Express Scripts slide template.) The video also confirms that SaveonSP/Express Scripts earns fees equal to 25% of the manufacturer’s copay support …Program Contact Information; Abilify: Bristol-Myers Squibb. Abilify. 1-800-736-0003 Patient Assistance Foundation. 1-888-922-4543 Assist Savings Program. Aristada: Alkermes: 1-866-274-7823 Aristada Care Support. Brintellix. Takeda: 1-800-830-9159 Help at Hand Patient Assistance Program. Clozapine (generic) Teva Clozapine: 1-800-507-8334 Patient ...

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Many pharmaceutical companies and specialty pharmacies have assistance programs that may be able to help patients cope with the financial aspects of a cancer diagnosis. For example, they may provide co-pay assistance to help people who have health insurance pay for the out-of-pocket costs associated with prescription drugs.collected on this enrollment form and through participation in the program for the following purposes: (1) To determine your eligibility for the program and to provide you with related services, including transfer to a separate private or public payer program, reimbursement services, services to ship your medication, and other support services.We can also help your patients navigate obstacles in receiving their prescribed ARISTADA INITIO and ARISTADA treatment with co-pay assistance for eligible patients, a patient assistance program, designation of an alternate patient contact, transition of care support, and appointment reminders if requested.Aristada Care Support This program provides brand name medications at no or low cost: Provided by: Alkermes, Inc. TEL: 866-274-7823 FAX: 844-464-7171: Languages Spoken: English, Spanish. Program Website : Patient Assistance Applications: Aristada Care Support Patient Assistance Program Enrollment FormCare Support & Aid: ARISTADA Care Assistance; Patient technology; Experiment ARISTADA; ARISTADA® Care Support also Assistance. Carolyne, processed with ARISTADA 882 mg. No matter find your patients are in the treatment journey, ARISTADA Care Support is there to help ...Proper management and administration of the Recipients and the Program, including re-disclosures to other Recipients, Providers, payors, and service providers as needed to operate the Program Revocation: You may revoke and cancel this Authorization by calling 1-833-468-7852 emailing [email protected] , or sending a written notice to Otsuka ...Call the ORGOVYX Support Program at 1-833-ORGOVYX (1-833-674-6899). * The ORGOVYX Copay Assistance Program (“Copay Program”) is for eligible patients with commercial prescription insurance for ORGOVYX. With this Copay Program, eligible patients will pay as little as $10 per month, subject to a maximum of $10,000 per …-- Retail Pharmacies, Including 900 Albertsons Locations, Added to the Provider Locator to Provide Injections of ARISTADA and VIVITROL; Additional Programs In Place to Deliver Support and Financial Assistance -- DUBLIN , May 11, 2020 /PRNewswire/ -- Alkermes plc (Nasdaq: ALKS) today announced theARISTADA® Take Support and Assistance Carolyne, addressed with ARISTADA 882 mg No matter where your patients exist in their treatment journey, ARISTADA Care Support lives there to help CVS Pharmacy. $3,643 retail. Save 15%. $ 3,085. Get free savings. Select this if your pharmacy isn’t listed above.HealthWell Foundation Copay Program Enrollment: Contact program : Medications: ARISTADA injection for suspension; extended-release (aripiprazole …o The first ARISTADA injection may be administered on the same day as ARISTADA INITIO or up to 10 days thereafter. See the ARISTADA INITIO prescribing information for additional information regarding administration of ARISTADA INITIO. o Avoid injecting both ARISTADA INITIO and ARISTADA concomitantly into the same deltoid or gluteal muscle. ….

Highest savings at fill is $1600.00 for ARISTADA 1064 milligram, up to 6 fills per calendar year, with maximum savings up to $7600 per agenda year. Maximum out-of-pocket cost per fill, after Co-pay savings applied, is $10. For ARISTADA INITIO, limit savings is up to $2000.00 total, and Co-pay card may becoming used up to 4 times at calendar year.The average Aristada price is about $3,636.37 depending on the strength and quantity you buy. Luckily, you can use SingleCare's Aristada discount card and pay $2,831.97 per 1, 3.2ml of 882mg/3.2ml Syringe at participating pharmacies near you. Brand. Syringe. 3.2ml of 882mg/3.2ml. Patient Assistance Program Co-pay savings Program Preferred Pharmacy name Phone # Fax # if Benefit Verification results specify a pharmacy other than preferred pharmacy, check here to allow triage to the pharmacy identified in Benefit Verification Pharmacist may inject nject M ARistADA 882mg every 6 weeks Patient Assistance Program Co-pay savings Program Preferred Pharmacy name Phone # Fax # if Benefit Verification results specify a pharmacy other than preferred pharmacy, check here to allow triage to the pharmacy identified in Benefit Verification Pharmacist may inject nject M ARistADA 882mg every 6 weeksCo-pay Savings Program and Patient Assistance Program ARISTADA Coverage Finder See what services ARISTADA Care Support Offers Find billing codes and reimbursement information Prior authorization and claims appeal assistance Find out how to order products or request samples Hospital Inpatient Free Trial ProgramARISTADA® Take Support and Assistance Carolyne, addressed with ARISTADA 882 mg No matter where your patients exist in their treatment journey, ARISTADA Care Support lives there to help The Department of Veteran Affairs (VA) Caregiver Support Program (CSP) offers clinical services to caregivers of eligible and covered Veterans enrolled in the VA health care system. The program’s mission is to promote the health and well-being of family caregivers who care for our Nation’s Veterans, through education, resources, support ...Highest savings at fill is $1600.00 for ARISTADA 1064 milligram, up to 6 fills per calendar year, with maximum savings up to $7600 per agenda year. Maximum out-of-pocket cost per fill, after Co-pay savings applied, is $10. For ARISTADA INITIO, limit savings is up to $2000.00 total, and Co-pay card may becoming used up to 4 times at calendar year. If you have advertiser general, you may be able to lower your out-of-pocket cost of treating use ARISTADA INITIO® (aripiprazole lauroxil) and/or ARISTADA® (aripiprazole lauroxil) through the ARISTADA Co-pay Savings Program. Your co-pay can will as low as $10 per prescription. Limitations apply. With more data and in see with to are eligible ...In today’s digital age, convenience is key. With just a few clicks, you can order groceries, pay bills, and even apply for government assistance programs. One such program is the EBT (Electronic Benefit Transfer) food stamps program. Aristada caresupport program co-pay, The following HCPCS codes apply for ARISTADA INITIO® (aripiprazole lauroxil) and ARISTADA® (aripiprazole lauroxil) for dates of service on or after October 1, 2019 †. …, Benefits verification Patient Assistance Program Co-pay savings Program PREsCRiBER oR FACiLity inFoRMAtion Prescriber 3. PAtiEnt inFoRMAtion name (First) (Middle initial) (Last) Date of Birth Gender Male Female Address City Mobile Phone # Phone instructions (Best number) state ZiP Code Home Phone # Email Address, Interested providers, including retail pharmacies and clinics, may contact ARISTADA Care Support (1-866-274-7823) or Vivitrol2gether SM (1-800-848-4876) to determine if they are eligible to be ..., Patient Assistance Program Co-pay savings Program Preferred Pharmacy name Phone # Fax # if Benefit Verification results specify a pharmacy other than preferred pharmacy, check here to allow triage to the pharmacy identified in Benefit Verification Pharmacist may inject nject M ARistADA 882mg every 6 weeks, ABILIFY may cause movements that you cannot control in your face, tongue, or other body parts. Tardive dyskinesia may not go away, even if you stop receiving ABILIFY. Tardive dyskinesia may also start after you stop receiving ABILIFY. Problems with your metabolism such as: High blood sugar (hyperglycemia) and diabetes., Title: LOC_US - PM-US-FVU-COUP-220003 - Trelegy MCM Downloadable Coupon Offer with Activation 2023_D2 Author: Saif Sayed Created Date: 20221213163307Z, The Amgen SupportPlus Co-Pay Program may help eligible patients with private or commercial insurance lower their out-of-pocket costs. Pay as little as $0* out-of-pocket for each dose (excluding Prolia ® and EVENITY ® ) †, Medication Guide at www.ARISTADA.com or call 1-866-ARISTADA. Page 3 of 5 ARISTADA® Provider Network Agreement Alkermes reserves the right to alter or discontinue this program at its discretion. If you wish to remove your organization, practice or any of your sites from this program please notify ARISTADA Care Support at 866 …, Call us: 1-866-ARISTADA (1-866-274-7823). Email us: [email protected]. Write to us: Alkermes, Inc. 852 Winter Street , We can also help our patients navigate hindernisse in receiving their prescribed ARISTADA INITIO and ARISTADA service with co-pay assistance used eligible patients, a patient assistance program, and designation of an change patient contact., Closed Program Resources for HEALTHCARE PROFESSIONALS ONLY. Contact program for details: www.AristadaHCP.com Co-payment assistance, …, Oct 4, 2023 · Learn more about the program Opens in new tab The ability to improve adherence right from the start with RespiPoints 1‡ Discover a behavior-changing support program that has a proven impact on adherence., A randomized, double-blind, placebo-controlled trial of aripiprazole lauroxil in acute exacerbation of schizophrenia. J Clin Psychiatry. 2015;76 (8):1085-1090. 3. Nasrallah HA, Aquila R, Du Y, Stanford AD, Claxton A, Weiden PJ. Long-term safety and tolerability of aripiprazole lauroxil in patients with schizophrenia., Proper management and administration of the Recipients and the Program, including re-disclosures to other Recipients, Providers, payors, and service providers as needed to operate the Program Revocation: You may revoke and cancel this Authorization by calling 1-833-468-7852 emailing [email protected] , or sending a written notice to Otsuka ..., By signing below, I (or my parent/guardian/legal representative) hereby give permission for my (or the patient’s) health care providers, pharmacies, service providers and their contractors, health plans, and health insurer(s) and their contractors, to disclose any and all necessary information, including, but not limited to, my (or the patient’s) income, …, -- Retail Pharmacies, Including 900 Albertsons Locations, Added to the Provider Locator to Provide Injections of ARISTADA and VIVITROL; Additional Programs In Place to Deliver Support and Financial Assistance -- DUBLIN , May 11, 2020 /PRNewswire/ -- Alkermes plc (Nasdaq: ALKS) today announced the, THE ARISTADA CO-PAY SAVE PROGRAM. For Illustrate Purposes Merely. Supposing you have commercial insurance, you may is able up reduce your out-of-pocket cost of treatment with ARISTADA INITIO® (aripiprazole lauroxil) and/or ARISTADA® (aripiprazole lauroxil) through the ARISTADA Co-pay Savings Select. Aristada Medicare Coverage …, Injection site reactions were reported by 4%, 5%, and 2% of patients treated with 441 mg ARISTADA (monthly), 882 mg ARISTADA (monthly), and placebo, respectively. Most of these were injection site pain and associated with the first injection and decreased with each subsequent injection. Other injection site reactions (induration, swelling, and ... , The ARISTADA Provider Network is compiled and published by Alkermes, Inc. as a reference source of demographic and professional information on individual licensed healthcare providers in the United States who have experience in the treatment of schizophrenia. The ARISTADA Provider Network is searchable by zip code or by city and state., DUBLIN, May 11, 2020 /PRNewswire/ -- Alkermes plc (Nasdaq: ALKS) today announced the expansion of several programs and services in support of patient access to its proprietary medicines during the COVID-19 crisis. During this unprecedented and rapidly evolving situation, the company remains focused on helping to assure that patients have …, ARISTADA® Take Support and Assistance Carolyne, addressed with ARISTADA 882 mg No matter where your patients exist in their treatment journey, ARISTADA Care Support lives there to help , Peak savings per fill is $1600.00 for ARISTADA 1064 mg, back to 6 fills per calendar year, with maximum savings up up $7600 per appointment year. Minimum out-of-pocket fees per fill, after Co-pay energy utilized, shall $10., 2 days ago · Victoza ® (liraglutide) injection 1.2 mg or 1.8 mg is an injectable prescription medicine used: along with diet and exercise to lower blood sugar (glucose) in adults and children who are 10 years of age and older with type 2 diabetes mellitus. to reduce the risk of major cardiovascular events such as heart attack, stroke, or death in adults ..., Aristada Initio Co-pay Savings Program. Eligible commercially insured patients may pay as little as $10 per prescription; offer may be used up to 4 times per calendar year with a maximum savings of up to $2000; for more information contact the program at 866-274-7823. Applies to: ARISTADA INITIO Number of uses: Per prescription until program ... , HealthWell Foundation Copay Program Enrollment: Contact program : Medications: ARISTADA injection for suspension; extended-release (aripiprazole …, ARISTADA. *Administer 1 injection of ARISTADA INITIO and a single 30 mg dose of oral aripiprazole with the first ARISTADA injection 5. If not starting with ARISTADA INITIO, administer oral aripiprazole for 21 consecutive days with the first ARISTADA injection 5. † IMPORTANT: Healthcare providers are responsible for keeping current and ... , Program offers co-pay assistance, reimbursement support, and forbearing assistance programs for eligible patients. Patients through Medicare Part D may be eligible, contact program for details. Income at or below: No Published: Medical expenses can be deducted upon reported income: , Medication Guide at www.ARISTADA.com or call 1-866-ARISTADA. Page 3 of 5 ARISTADA® Provider Network Agreement Alkermes reserves the right to alter or discontinue this program at its discretion. If you wish to remove your organization, practice or any of your sites from this program please notify ARISTADA Care Support at 866 …, Insurance plan coverage for Victoza ®. Victoza ® is covered by most major health plans, including Medicare and Medicaid. If you have questions about insurance plan coverage and co-pay costs for Victoza ®, please call 1-877-4VICTOZA (1-877-484-2869).With some basic insurance information, you can check your benefits and find out how much you'll pay for …, NeedyMeds has free information on medication and healthcare fee savings programs inclusion prescription supports programs and medical plus dentistry hospitals. , Patient Assistance Program Co-pay savings Program Preferred Pharmacy name Phone # Fax # if Benefit Verification results specify a pharmacy other than preferred pharmacy, check here to allow triage to the pharmacy identified in Benefit Verification Pharmacist may inject nject M ARistADA 882mg every 6 weeks, Aristada Care Support This program provides brand name medications at no or low cost: Provided by: Alkermes, Inc. TEL: 866-274-7823 FAX: 844-464-7171: Languages Spoken: English, Spanish. Program Website : Patient Assistance Applications: Aristada Care Support Patient Assistance Program Enrollment Form, Oct 10, 2023 · Aristada Care Support Patient Assistance Program Enrollment Form 08/15/23 ASSIST Program: Contact program Astellas Pharma Support Solutions (MYRBETRIQ): Contact program Astellas Pharma Support Solutions (PADCEV) Enrollment Form 09/11/23