* Are you, or the patient currently enrolled in Medicare, Medicare Part D, Medicaid, TriCare, Veterans Administration, State Pharmaceutical Assistance programs, or other Federal or State programs? This program is not valid for prescriptions reimbursed under Medicare, Medicaid, VA, DoD, (TRICARE), Indian Health Services, or other similar federal or state program.

Yes

* Is the patient enrolling in the program 18 years of age or older?

Yes

* Please indicate the state in which the patient resides

* First Name

* Last Name

* Gender

Male

Female

* Date of Birth (mm/dd/yyyy)

* Street Address

Address 2

* City

* Zip Code (numbers only)

* Phone Number

* Email Address

* Please indicate the Specialty Pharmacy you wish to fill your prescription at

Accredo

CVS Specialty "Caremark"

Unsure

* By enrolling, I agree to have my personal information used to provide me with information and resources regarding products, programs, and services related to my condition, including treatment information. Information sent by United Therapeutics does not take the place of talking to your healthcare provider about your treatment or condition. United Therapeutics, or third parties working on its behalf, will not sell your information or use it for unrelated purposes. If in the future you no longer want to receive these materials or participate in these programs, please call 877-864-8437.

Yes

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