Download helpful resources 

Feraheme Assist Patient Assistance Program Patient Application
Provide this form to your patients that are uninsured or functionally underinsured so they can enroll in Feraheme Assist Patient Assistance Program. Please ensure that you have submitted a completed HCP PAP Enrollment Form. Patients should return this form and the required income documentation to [email protected] or mail to AllCare Plus Pharmacy, 50 Bearfoot Road, Northborough, MA 01532
Feraheme Assist Patient Assistance Program HCP Enrollment Form
Use this form to enroll your uninsured and functionally underinsured patients in the Feraheme Assist Patient Assistance Program, a program that provides eligible patients with free product. Please fill out the information and email to [email protected] or fax to 877-591-2505.
Referral Form
You can use this form to refer your patients to another physician to receive FERAHEME.
Radiologist Letter
This letter provides radiology departments information on how to adjust the MRI equipment for patients who have had a recent FERAHEME injection.
AMAG Returns and Replacement Policy
This form can be used to review the FERAHEME returns and replacement policy as well as to submit a product replacement request.
Billing and Coding
This brochure helps with billing and coding for outpatient services. Codes include product, administration, and diagnosis codes, as well as coding for IDA underlying conditions.
Sample 1450 Billing Form
This form gives direction on how to complete the the standard claim form to bill Medicare Administrative Contractors (MACs) when a paper claim is allowed.
Sample 1500 Billing Form
This form gives direction on how to complete the standard claim form used to bill the services of the healthcare professional performed in the hospital or the Ambulatory Surgical Center.
Prior Authorization Checklist
This checklist is a helpful tool to ensure all prior authorization requests are complete.
Sample Letter of Medical Necessity
You can use this template to help you write a letter of appeal if a health plan denies FERAHEME coverage.

IDA=iron deficiency anemia; MRI=magnetic resonance imaging.

FERAHEME patient brochure (English)
Educational material that provides your patients with the information they need to get started on FERAHEME.