This site is intended for US healthcare professionals

Forms and Templates

Forms

Patient Assistance/Benefits Investigation Enrollment Form (English) Icon
Patient Assistance/Benefits Investigation Enrollment Form (English)
Download
Patient Assistance/Benefits Investigation Enrollment Form (English - Online Submission) Icon
Patient Assistance/Benefits Investigation Enrollment Form (English - Online Submission)
Enroll

Sample Forms and Templates

Letter of Medical Necessity Template Icon
Letter of Medical Necessity Template
Download
Sample Claim Form (CMS 1500 — Physician Office) Icon
Sample Claim Form (CMS 1500 — Physician Office)
Download
Sample Claim Form (CMS 1450 — Hospital Outpatient) Icon
Sample Claim Form (CMS 1450 — Hospital Outpatient)
Download

Downloadable Resources

ADCETRIS® (brentuximab vedotin) Prescribing Information Icon
ADCETRIS® (brentuximab vedotin) Prescribing Information
Download
Glossary of Terms Icon
Glossary of Terms
Download

Enroll Your Patient

Enroll by calling a SeaGen® Secure Case Manager:

855-4SECURE (855-473-2873) Option 1 for HCPs, Option 2 for Patients

Monday through Friday, 9 am – 8 pm EST

You can also download an enrollment form or fill one out online:
Enroll Now

Enroll your patient to gain access to comprehensive services and support

Online Enrollment

Online enrollment is simple and only takes a few minutes.

Enroll Online

Digital PDF

Download the enrollment form on your computer and fax to 855-552-2480 or use the embedded email link.

Download PDF