Directions: For assistance, please complete this form and fax it to 1.855.854.3931. You can also call 1.844.472.2628, Monday-Friday 8 am–6 pm ET, to speak with a Vivimusta CONNECT® Case Manager.
SERVICES REQUESTED
REQUIRED FIELDS ARE MARKED IN BOLD. PLEASE NOTE THAT MISSING INFORMATION WILL DELAY OUR ABILITY TO ASSIST YOU IN ACCESSING SUPPORT
1
PATIENT DEMOGRAPHIC INFORMATION
2
PATIENT INSURANCE
Primary Medical Insurance Information
Secondary Medical Insurance Information
3
PHYSICIAN INFORMATION
4
TREATMENT INFORMATION
5
PRESCRIPTION (Complete this section only if the patient is applying to the patient assistance program)

Vivimusta® (bendamustine HCl) injection 100 mg/4 mL (25 mg/mL) multi-dose vial

6
PRESCRIBER CERTIFICATION AND SIGNATURE (Complete this section only if the patient is applying to the patient assistance program)

By signing below, I certify that (1) the above therapy is medically necessary and in the best interest of the patient listed above; (2) the information provided is complete and accurate to the best of my knowledge; (3) I have obtained any and all authorizations and consents from the patient or the patient’s authorized personal representative necessary under HIPAA and state law to release protected health information, including that contained on this form, to Azurity Pharmaceuticals and its affiliates, vendors, and agents for purposes relating to the Vivimusta CONNECT® Program, to solely assist with benefits verification, prior authorization/appeals assistance, and forwarding the above prescription by fax or other means of delivery to a licensed pharmacy to dispense Vivimusta® where appropriate; and (4) I agree to the Business Associate Agreement as presented at https://baa.vivimustaconnect.com/.

Vivimusta® is a trademark of Azurity Pharmaceuticals, Inc.

© 2025 Azurity Pharmaceuticals, Inc. All Rights Reserved. All trademarks referred to are the property of their respective owners.

PP-VIV-5305-US-EN-v1 10/25

VIVIMUSTA