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BioMarin Product Replacement

Please select the appropriate form below.

Only Specialty Pharmacies should complete the Specialty Pharmacy form. Site of Care centers who have purchased product directly from BioMarin should complete the Site of Care form.

Product Replacement Attestation Form for Specialty Pharmacy on behalf of Patients

Special Pharmacy Information

NOTE: If you are a hospital-based Specialty Pharmacy, please complete the Site of Care form

Patient Information
Specialty Pharmacy Attestation On Behalf of the Patient

I declare that the information in this form is true and correct.

My patient has requested replacement medication because the Product our pharmacy dispensed to the patient has since been rendered unsaleable by the patient through unintentional, unplanned circumstances. The patient explained to me as follows (please check all that apply*):

(1000 characters remaining)

I certify this was an unsolicited request and that the patient informed me that they have not used any amount of the unsaleable Product and that (please choose one*):

Or

†For multi-unit packaging configuration, the unused Product pack will be returned to BioMarin or the entire Product pack must be destroyed.

If BioMarin approves the patient’s request for replacement medication, I shall communicate to the patient that (i) the replacement medication will be provided to the patient at no charge, (ii) there is no purchase requirement associated with the patient’s receipt of the replacement medication, (iii) the replacement medication is not intended as a reward or inducement for the purchase of any product, and (iv) the patient may not resell or transfer the replacement medication to any other individual or entity for any purpose.

By entering my name below and submitting this form, I hereby attest that the information provided in the form above is true and correct.

Please upload a single image of Product damage, if available, (jpeg, gif, png, pdf format only, not to exceed 5 MB in size) or check the box to confirm that no photo of Product damage or impairment is available.


Product Replacement Attestation Form for Sites of Care

Provider Information
Provider Attestation

I declare that the information in this form is true and correct.

I am requesting replacement medication from BioMarin because the Product I purchased has been rendered unsaleable through unintentional, unplanned circumstances. (Please check all that apply*):

(1000 characters remaining)

I certify that I, or my staff, received an unsolicited request and have not administered any amount of the unsaleable Product to a patient. I further certify that I, or my staff, have not sought payment or accepted reimbursement from any patient or third-party payor, including any state or federal entity or any private or other insurance plan, for the unsaleable Product, and that (please choose one*):

Or

†For multi-unit packaging configuration, the unused Product pack will be returned to BioMarin or the entire Product pack must be destroyed.

If BioMarin approves my request for replacement medication, I understand that (i) the replacement medication will be provided to me at no charge, (ii) there is no purchase requirement associated with my receipt of the replacement medication, (iii) the replacement medication is not intended as a reward or inducement for any referrals, and (iv) I may not resell or transfer the replacement medication to any other individual or entity for any purpose.

By entering my name below and submitting this form, I hereby attest that the information provided in the form above is true and correct.

Please upload a single image of Product damage, if available, (jpeg, gif, png, pdf format only, not to exceed 5 MB in size) or check the box to confirm that no photo of Product damage or impairment is available.