BioMarin Product Replacement

Please select the appropriate form below.

Only Specialty Pharmacies should complete the Specialty Pharmacy form. Site of Care centers who have purchased product directly from BioMarin should complete the HCP/Site of Care form.

Specialty Pharmacy Product Replacement Attestation for Patients

Special Pharmacy Information
Patient Information
Specialty Pharmacy Attestation On Behalf of the Patient

I declare that the information in this form is true and correct.

My patient has requested replacement medication because the Product our pharmacy dispensed to the patient has since been rendered unusable by the patient through unintentional, unplanned circumstances. The patient explained to me as follows (please check all that apply*):

(1000 characters remaining)

I certify this was an unsolicited request and that the patient informed me that they have not used any amount of the unusable Product and that (please choose one*):

Or

If BioMarin approves the patient’s request for replacement medication, I shall communicate to the patient that (i) the replacement medication will be provided to the patient at no charge, (ii) there is no purchase requirement associated with the patient’s receipt of the replacement medication, (iii) the replacement medication is not intended as a reward or inducement for the purchase of any product, and (iv) the patient may not resell or transfer the replacement medication to any other individual or entity for any purpose.

By entering my name below and submitting this form, I hereby attest that the information provided in the form above is true and correct.

Please upload a single image of Product damage, if available, (jpeg, gif, png, pdf format only, not to exceed 5 MB in size) or check the box to confirm that no photo of Product damage or impairment is available.


HCP/Site of Care Product Replacement Attestation for Providers

Provider Information
Provider Attestation

I declare that the information in this form is true and correct.

I am requesting replacement medication from BioMarin because the Product I purchased has been rendered unusable through unintentional, unplanned circumstances. (Please check all that apply*):

(1000 characters remaining)

I certify that I, or my staff, received an unsolicited request and have not administered any amount of the unusable Product to a patient. I further certify that I, or my staff, have not sought payment or accepted reimbursement from any patient or third-party payor, including any state or federal entity or any private or other insurance plan, for the unusable Product, and that (please choose one*):

Or

If BioMarin approves my request for replacement medication, I understand that (i) the replacement medication will be provided to me at no charge, (ii) there is no purchase requirement associated with my receipt of the replacement medication, (iii) the replacement medication is not intended as a reward or inducement for any referrals, and (iv) I may not resell or transfer the replacement medication to any other individual or entity for any purpose.

By entering my name below and submitting this form, I hereby attest that the information provided in the form above is true and correct.

Please upload a single image of Product damage, if available, (jpeg, gif, png, pdf format only, not to exceed 5 MB in size) or check the box to confirm that no photo of Product damage or impairment is available.