EveryDay Support From Day One Enrollment Form

Fill out the fields below to complete the enrollment form online or download the form and return it via fax or email.

Prescriber Information

An asterisk (*) indicates a required field

Required fields are incomplete. Please complete highlighted fields to continue.

Note: Some fields may populate based on NPI records on file with CMS. Please confirm the accuracy of prepopulated information and update if needed.

Patient Information

Insurance Information

*Please indicate your patient's insurance status.

Patient insurance status

*How do you want to provide insurance information?

Insurance entry method

    Primary Insurance

    Please provide patient's insurance information for prescription medications

    Clinical Information

    QuickStart Prescription Information and Signature

    *Do you want your patient enrolled in the QuickStart program in case of a coverage delay?

    Please note: Patient must have a diagnosis consistent with the FDA-approved indication

    Enroll in QuickStart selection

    Please complete the QuickStart prescription below. If an e-prescription is preferred, it can be sent to RareMed Solutions at NPI #: 1043877996.

    OJEMDA™ (tovorafenib) Prescription Notes

    • Dosing: 380 mg/m2/ once a week
    • It is recommended that patients with BSA ≤0.89 m2 receive oral suspension
    • For patients with BSA ≥0.90 m2 who require oral suspension, please use "other" line in oral suspension section
    OJEMDA 25 mg/mL Oral Suspension (0.30 m2 to 0.89 m2 BSA)

    Dispense quantity needed for up to 28 days with PRN (as needed) refills according to program rules.
    OJEMDA Tablets (≥0.90 m2 BSA)

    Each tablet is 100 mg

    Dispense quantity needed for up to 28 days with PRN (as needed) refills according to program rules.

    My signature certifies that the person named on this form is my patient, the information provided is complete and accurate to the best of my knowledge, and that therapy with OJEMDA™ (tovorafenib) is medically necessary. I certify that I have obtained my patient's authorization in accordance with all applicable state and federal laws to release the individually identifiable health information included on this form to Day One Biopharmaceuticals, Inc.'s (“Day One”) EveryDay Support From Day One patient support program (“Program”), and I understand the information I provide on this form will be used for the purpose of verifying my patient's insurance, determining eligibility for Program offerings, and contacting my patient regarding Program support. I authorize the Program to transmit the above prescription to a specialty pharmacy for my patient. I understand that I am under no obligation to prescribe any Day One product and that I have not received, nor will I receive, any benefit from Day One for doing so. I will not seek reimbursement from any third-party payer, patient, or other person or entity for any product provided free of charge by the Program. I attest that I am not on the HHS/OIG List of Excluded Individuals/Entities (LEIE).

    Special Note: The prescriber is to comply with the prescriber's state-specific prescription requirements. New York prescriber, please use an original New York state prescription form.

    File upload

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      Prescriber signature is required

      Checkbox must be checked

      Special Note: The prescriber is to comply with the prescriber's state-specific prescription requirements. New York prescriber, please use an original New York state prescription form.

      Success! Thank you for submitting your enrollment form

      Next steps:

      1. Please submit your patient's prescription to Biologics or Onco360 using your normal prescribing process.
      2. Your patients must provide their consent. Patients can consent electronically at www.everydaysupport.com/consent.
      3. Download a copy of the completed enrollment form for your records. Download a copy of the completed enrollment form

      If you have any questions, call 855-DAY1-BIO/855-329-1246.

      An error has occurred

      There is an error with the electronic submission of your enrollment form, and it cannot be completed online at this time. Your information has been saved and can be accessed by clicking the button below.

      Please download the form below and submit it via fax to 855-332-9663 or email [email protected].

      Download a copy of the completed enrollment form

      Please note: To complete enrollment, your patient must provide their consent. Patients can consent electronically at www.everydaysupport.com/consent.

      If you have any questions, call 855-DAY1-BIO/855-329-1246.