Forms and Documents
- XOSPATA Support SolutionsSM Patient Enrollment Form
(PDF - 204 KB) - 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 - 1.02 MB) - Medicare Extra Help Patient Flashcard (Spanish)
(PDF - 1.70 MB)
XOSPATA® is a registered trademark of Astellas Pharma Inc.