Arakoda – Protecting global travelers from malaria

Enrollment Form

*Denotes mandatory fields

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Patient Gender*

Patient Address 1*

Patient Address 2

City*

State*

ZIP Code*

Copay Card Delivery Method*

SMS (mobile text message)

Email Address*

Cell Phone*

I am 18 years of age and live in the United States.*

Yes

What type of insurance do you use for your ARAKODA prescription?*

Commercial Insurance

Government

I don't know

I don't have insurance

Eligibility*

Not all patients are eligible for the copay assistance program, but if eligible, the patient understands and authorizes the sharing of their personal health information by the pharmacy with 60 Degrees Pharmaceuticals, the sponsor of the card, and its partners supporting the copay card assistance programs as necessary to: provide services to the patient under such programs; ensure effective administration and operations of such programs; transition the patient's support; or share their information with service providers for the purpose of aggregation or de-identification.

This information may include the personal information provided by the patient for copay enrollment, payor-related information received from their health insurer, and any prescription, fulfillment, and other information provided by my pharmacy. Should the patient begin receiving prescription benefits from a federal, state, or other government-funded programs at any time, the patient will no longer be eligible to participate in this program.

The patient may also be contacted periodically in order to verify that their eligibility for the program has not changed.

Does the patient agree to these statements?

Yes

By checking this box I agree that I read, understand, and accept the terms and conditions of the ARAKODA Copay Program.*

Copay Enrollment

Save With Enrollment in the ARAKODA Copay Program

See if you are eligible to save on your ARAKODA prescription

Need help?

Enrollment Form