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Page 1: include proof of payment as part of the document ... · include proof of payment as part of the document submission. When selecting Practice: by checking this box, the Practice certifies

© 2018 Amgen Inc. All rights reserved. Not for Reproduction.

When selecting Patient: In addition to the documentation required by the program, please ensure to include proof of payment as part of the document submission.

When selecting Practice: by checking this box, the Practice certifies that they only billed the patient for the appropriate amount of out-of-pocket cost for Prolia® after application of the Prolia® Co-pay Card benefits.The check will be mailed to the address provided for the marked recipient. Please make sure to provide the corresponding address in this form.

USA-162-048018(1)

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