Forms and Documents
- XOSPATA Support SolutionsSM Patient Enrollment Form
(PDF - 2.51 MB) - Sample Letter of Medical Necessity
(PDF - 158 KB) - Sample Letter of Denial Appeal
(PDF - 108 KB) - Patient Authorization Form
(PDF - 244 KB) - Medicare Extra Help Patient Flashcard
(PDF - 3.43 MB) - Medicare Extra Help Patient Flashcard (Spanish)
(PDF - 3.41 MB)
To access insurance-related forms (including prior authorization forms) for Astellas products, please click here.
If you do not see a form that you need, please call us at 1-844-632-9272. We are available Monday–Friday, 8:30 am–8:00 pm ET.
XOSPATA® is a registered trademark of Astellas Pharma Inc.