Access an IncyteCARES Enrollment Form
A completed IncyteCARES Program Enrollment Form can also serve as your patient's first prescription. Completion takes about 15 minutes.
Select the enrollment form for the medication you would like to prescribe.
To Submit Via Fax
This PDF form for JAKAFI XR can be downloaded and filled out on computer to print and sign or can be printed and filled out by hand before faxing.
To Submit Via Secure Website
There’s no need to set up an account or password. For security, information you enter in the online enrollment form is not saved when you close it.
To Submit Via Fax
This PDF form for JAKAFI can be downloaded and filled out on computer to print and sign or can be printed and filled out by hand before faxing.
To Submit Via Secure Website
There’s no need to set up an account or password. For security, information you enter in the online enrollment form is not saved when you close it.
Patients who have been prescribed JAKAFI or JAKAFI XR can enroll in IncyteCARES but may not be eligible to receive some of the services or support we offer. Contact IncyteCARES at 1-855-452-5234 for more information.
For Eligible Patients With Commercial Prescription Insurance
Enroll Your Patient in the Savings Program Only
Follow These Simple Steps
Save time by gathering required patient information before you start!
Step 1: Complete the Patient Information (or have your patient complete it) including:
- Patient shipping address for medication delivery
- Contact phone number(s)
- Prescription insurance information
- Financial information (if being considered for Patient Assistance Program)
Step 2: Complete the Physician Information including:
- Practice and provider information
- Patient’s clinical information
- Patient’s prescription details
Step 3: Fax or submit an IncyteCARES Program Enrollment Form
- Form can be submitted with or without the signed patient HIPAA Authorization and Patient Opt-in for Ongoing Education and Support
- If the patient is available, have them sign the HIPAA Authorization and Patient Opt-in for Ongoing Education and Support sections
- If the patient isn’t available to sign those sections, they can be left blank and IncyteCARES will call the patient to get verbal authorization
Patient authorization is not needed for benefits verification.
When You Enroll a Patient, an IncyteCARES
Representative Will:
- Call your patient to welcome them and explain their insurance coverage
- Assess your patient’s eligibility for savings or financial assistance programs* and help them enroll
- Explain the additional support and resources available to them during treatment
*Terms and conditions apply. Terms of this program may change at any time.
Did You Know?
Sometimes, patients contact IncyteCARES directly to start an enrollment. In that case, a representative will take the patient’s information and will contact the prescriber’s office to gather the additional information needed to qualify and enroll the patient.
Contact IncyteCARES
Our team is available Monday through Friday, 8 AM–8 PM ET
Call us at 1-855-452-5234
