TORISEL Billing and Reimbursement Forms
Use these forms to get reimbursement support when you prescribe TORISEL.
- Download the Patient
Enrollment and Application form
(Adobe PDF) - Download the Physician
Enrollment and Application form (Adobe PDF)
- Download the HIPAA
Authorization form (Adobe PDF)
NOTE: In order to download the following templates for Letters of Medical Necessity and Claim Denial Appeals, you must be registered and signed in as a health care professional at Wyeth.com. If you are not yet registered, Register Now.
- Download the template for Letters of Medical Necessity (Adobe PDF)
- Download the template for Claim Denial Appeals (Adobe PDF)
Documents are in PDF (Portable document format). PDF files require Adobe® Reader®;
Download the free Adobe Reader.
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