eHIPAA

Questions?
Call CAP

1-877-722-9786

Hours of Operation
(Monday–Friday 8AM – 8PM EST)

Cayston, CAP and the Cayston logo are
trademarks of Gilead Sciences, Inc.
ADMC0491 03/20

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About This Form

CAP is a patient support program designed to provide information about your CAYSTON® (aztreonam for inhalation solution) coverage, triages to Specialty Pharmacy for fulfillment, and other support offerings. CAP is an agent of Gilead Sciences, Inc. In order to provide financial assistance and information, Gilead Sciences will need to use your health information (called “Protected Health Information” or “PHI”), and to share it with your health plan and the pharmacy that will receive your doctor’s prescription. This authorization will allow your health care providers, and health insurers that maintain PHI about you to disclose your PHI to Gilead Sciences, Inc. and its contractors and agents so that the Support Center may provide financial assistance and information to you, or on your behalf.

Patient Information

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Address 1 *

Address 2

City *

Zip Code *

Alternate Contact Information

Alternate Contact Name

Relationship to Patient

I am signing as parent or guardian (personal representative) of the patient.

Prescriber Information

Prescriber Name

Prescriber Phone #

555-555-5555

Contact Information

Email Address *

Patient Cell # *