Help Patients Get Started

Completing The prescription start form

Before getting started, download the Prescription Start Form and then follow the steps below.

Download Prescription Start Form
EMFLAZA® (deflazacort) Prescription Start Form

For patient and caregivers

  • Step 1

    Download the Prescription Start Form

  • Step 2

    Complete patient and insurance information on the patient side of the form

  • Step 3

    Having the patient/guardian sign at the bottom of the form will prevent delays in processing the prescription

EMFLAZA® (deflazacort) Prescription Start Form

For the prescriber

  • Step 1

    Sign both prescriptions (Primary and Bridge) in the Prescription Information section of the form. This will ensure your patient has ongoing access to EMFLAZA

  • Step 2

    Sign at the bottom of the form where it says “Prescriber Authorization Signature”

  • Step 3

    PTC Cares may also need additional documentation, such as:

    • Statement of medical necessity
    • ICD-10 code
    • Chart notes or dosage changes
    • Patient’s prior medical history of taking prednisone
PTC Cares™

Once patient enrollment has begun, PTC Cares manages each step of the prescription process

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