A Collaborative Approach to Enrollment

Nuvalent Patient Support can help facilitate enrollment for eligible patients prescribed JIDEYTRO by providing support throughout the process and guidance on the information needed for program participation.

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How to Enroll Your Patient in Nuvalent Patient Support

Nuvalent Patient Support Enrollment Options:

Option 1: eEnroll

Complete and submit online enrollment form. Please note: ePrescribe or fax prescription separately.

Online Enrollment Form

Option 2: Download Form

Download and complete the enrollment form and submit via fax with the accompanying prescription.

Download Enrollment Form

Important Information

During the enrollment process, you will be asked to include copies of your patient’s insurance card. For underinsured patients who are seeking to enroll in the Patient Assistance Program^†, please include a copy of the first-level appeal denial letter.

Obtaining patient consent

Patient signatures are required to complete enrollment. They may sign the physical form or visit the online patient form to sign online. Please provide the link for the online patient form to your patients to complete.

If you are unable to obtain a patient signature, Nuvalent Patient Support will reach out to your patient via phone or email to obtain this signature. Let your patient know to expect this communication from Nuvalent Patient Support in order to complete enrollment. They may also contact us directly at (844) 688-5333.

For more details about how to submit the Nuvalent Patient Support Enrollment Form, download the Nuvalent Patient Support Enrollment Form Guide or call (844) 688-5333 for assistance.

Copay Assistance Program*

Is your patient interested in copay support? Eligible commercially insured patients prescribed JIDEYTRO may pay as little as $0.

Note: Patients do not have to be enrolled in Nuvalent Patient Support to sign up. For more information about eligibility, visit Financial Assistance Programs.

*Please see Copay Assistance Program terms and conditions. Patients covered by Medicare, Medicaid, or any other state or federal government-funded plan are not eligible for the Copay Assistance Program. Maximum program benefit per calendar year applies.

^†Please see the Patient Assistance Program terms and conditions