Bexxar Forms

• RRC - Prior Authorization Assistance - Administering Site and Physician Enrollment Form
• RRC - Patient Information Form
• RRC - Prior Authorization - Bexxar - Referring Physician Enrollment Form
• RRC - Patient Authorization to Release and Disclose Medical Information Form

Forms for all other GSK Products

• Patient Authorization Form - Patients will be required to sign a written release of medical information and authorization statement in order for GlaxoSmithKline to provide patient-specific assistance. If you are also requesting verification of benefits, please use the "Benefit Verification Request Form" below in lieu of this form.
• Benefit Verification Request Form - Call 800-745-2967 or fax this form to request verification of benefits.

GSK Reimbursement Resource Center Brochure - This brochure describes the services provided through the GSKRRC. Call 800-745-2967 to request hard copies by mail.