Acthar Patient Support

Start the Referral Process With the Acthar Referral Form

Once you submit a completed Acthar Referral Form to Acthar Patient Support, your patient will begin receiving support

To get the prescription and reimbursement process started:

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  1. Complete the Acthar Referral Form
  2. Fax to Acthar Patient Support at 1-877-937-2284


Download the Acthar Referral Form

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You can also submit forms directly through the Acthar Provider Portal


Visit the Provider Portal


Your Case Manager will fax back a confirmation and contact your office typically within 4 business hours to explain next steps, including prior authorization requirements.

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Let patients know:

  • Acthar Patient Support and the Specialty Pharmacy will contact them by phone via a 1-800 number, which may appear as “blocked” or “unavailable”
  • Call back if they miss the call to keep the approval process moving forward
  • Upon referral, Acthar Patient Support will send your patient tools to help them through the process

Your Case Manager may also contact your office if there are questions. Responding in a timely manner helps ensure patients get Acthar Gel as soon as possible

Why patient consent on page 3 is important

When a patient signs page 3 of the Acthar Referral Form, they enable our complete level of support by authorizing Acthar Patient Support to interact with some pharmacies and insurance providers on their behalf.

If your patient hasn’t signed page 3, it takes just a few minutes to complete electronically at

Make sure each Acthar Referral Form is complete

The Acthar Referral Form Guide includes easy-to-follow instructions for completing an Acthar Referral Form, including recommended dosing information, patient authorization, and scheduling injection training.

Need support now or want to request injection training for a patient?
Acthar Patient Support is available

Online at

And by phone at


Monday through Friday, 8 AM to 9 PM ET
Saturday, 9 AM to 2 PM ET