Online AkebiaCares Patient Support

A completed AkebiaCares enrollment form is the first step for AkebiaCares to assist patients.

For the best experience, we recommend using your desktop to complete this form. If you need assistance completing this form, AkebiaCares Case Managers can be reached at 1‑833‑4AKEBIA (425‑3242), Monday - Friday, 8AM - 8PM ET. This form will take approximately 15 minutes to complete.

*Indicates required field

Please select what you are filling out this form for*:
One or more sections below have not been completed properly.

A Patient information One or more fields have not been completed properly.

One or more fields have not been completed properly.
Please enter a first name.
Please enter a last name.
Please enter a valid DOB.
Is the patient a US citizen?*
Please make a selection above.
Please enter a valid street address.
Please enter a valid city.
State*
Please select a state.
Please enter a valid ZIP code.
Preferred language
Relationship to patient
Please enter a valid phone number.
Please enter a valid email.
Is the patient on dialysis?
Gender*
Please make a selection above.

After completing the required fields, click "Next section" to move on to the subsequent section. Manually changing sections will result in error messages.

B Prescription drug insurance information One or more fields have not been completed properly.

One or more fields have not been completed properly.

Patient does not have insurance (optional)

Please enter a primary insurance.
Please enter an Rx PCN#.
Please enter an Rx BIN#.
Please enter an Rx Group#.
Please enter a cardholder name.
Please enter a prescription insurance member ID#.
Please enter a Medicare ID#.
Please enter the name of the patient-preferred pharmacy.
Please enter a valid address.
Please enter a valid city.
State*
Please select a state.
Please enter a valid ZIP.
Please enter a valid phone number.
Please enter a valid fax number.

C Income information† One or more fields have not been completed properly.

One or more fields have not been completed properly.
If you have Medicare Part D and have applied for Medicare's Low-Income Subsidy (Extra Help), which of the following outcomes did you receive?*
Please make a selection above.
Please enter a number.

(Include all income: wages, pension, Social Security, disability, alimony, interest/dividends, rental property income, etc)

Please enter total annual household income.

†AkebiaCares or its agents will run a soft credit check to assist with income verification. A soft credit check will not appear on the patient's credit statement or impact their credit score. Akebia has the right to require written proof of income (such as a Form 1040, Form W-2, or other documentation) from patients in connection with a financial eligibility determination should the Automated Income Verification process produce invalid or no results.

‡Your household size includes all individuals you reported on your U.S. Tax Return. If you did not file a tax return, please include all individuals that live with you.

D Patient HIPAA authorization to use and share protected health information One or more fields have not been completed properly.

One or more fields have not been completed properly.

If the patient is NOT currently in the office to provide their own signature, check this box. If this field is checked, this section of the form will no longer need to be completed at this time. The patient will receive an email with a DocuSign link that they will use to provide their signature.

If the patient is in the office but prefers to sign electronically through text or email, check this box.

By signing below, I authorize my healthcare professionals, including my physicians and pharmacies (“My Providers”), and my health insurance plan (“My Plan”) to use and share my identifiable medical information (such as information about my diagnosis and treatment) and my identifiable insurance information (collectively, “My Information”) with Akebia Therapeutics, Inc., and its subsidiaries (including Keryx Biopharmaceuticals, Inc.), affiliates, representatives, agents, and contractors (“Akebia”) so that Akebia can: provide me with information, assistance, and support through AkebiaCares (“Patient Support”) as described below; administer and analyze the effectiveness of AkebiaCares; ask if I am interested in participating in clinical trials and market research; review eligibility for financial assistance; carry out other business purposes related to Akebia products; and comply with law. I understand and agree that my pharmacies may receive payment from Akebia in exchange for sharing My Information with Akebia. Once My Information has been shared with Akebia, federal privacy laws may no longer protect the information. However, Akebia agrees to protect My Information by using and disclosing it only for the purposes described in this authorization. I may refuse to sign this authorization and doing so will not affect my treatment, insurance coverage, or eligibility for benefits for which I am otherwise entitled. However, refusing to sign this authorization means that I cannot participate in AkebiaCares. I may cancel or revoke this or any portion of this authorization at any time by mailing a letter to AkebiaCares, P.O. Box 5490, Louisville, KY 40255 or by sending an email to support@akebiacares.com. If I revoke or limit this authorization, My Providers and My Plan will stop using and sharing My Information, but my revocation will not affect uses and disclosures of My Information made in reliance upon this authorization prior to my revocation. This authorization expires ten (10) years from the date signed below, or earlier if required by state or local law, unless I revoke it before then. I will receive a copy of my signed authorization.

Please enter a patient or authorized patient representative name.
Relationship to patient
Please enter a patient or authorized patient representative signature.
Please enter a valid date.

§The authorized patient representative may not be the patient's healthcare professional.

E Patient consent to participate in AkebiaCares One or more fields have not been completed properly.

One or more fields have not been completed properly.

Check this box if the patient is NOT currently in the office to provide their own signature. If this field is checked, this section of the form will no longer need to be completed at this time. The patient will receive an email with a DocuSign link that they will use to provide their signature.

AkebiaCares is a program administered by Akebia that provides Patient Support to eligible patients who have been prescribed an Akebia medication. Patient Support includes: (1) providing reimbursement and assistance with financial support (including, but not limited to, investigating insurance coverage, confirming out-of-pocket costs, and reviewing eligibility for financial assistance); (2) working with patients and their healthcare professionals to fill their prescriptions; and (3) providing patients with disease and medication-related educational resources and communications.

I acknowledge that Akebia may use My Information and share it with My Providers or My Plan in connection with providing Patient Support and for the other purposes described in the authorization above. I expressly permit Akebia to (1) contact me or my representative, using contact information that I provide, through any medium, including, but not limited to, mail, telephone, text message, or email; (2) use My Information to tailor AkebiaCares-related communications to my needs; and (3) share information with My Providers about dispensing an Akebia product to me. Akebia may also de-identify My Information and use the de-identified information for Akebia's business purposes. I understand that AkebiaCares is an optional program and that my treatment, insurance enrollment, and insurance eligibility are not conditioned upon providing consent. I also understand that refusing to consent will make me ineligible to participate in AkebiaCares. If I provide consent, I may revoke it at any time by mailing a letter to AkebiaCares, P.O. Box 5490, Louisville, KY 40255, sending an email to support@akebiacares.com, or following the opt-out instructions in any correspondence that I receive. If my contact or insurance information changes at any time while I am participating in AkebiaCares, I will notify AkebiaCares as soon as possible by using the physical or email address provided above. By signing below, I confirm that I would like to enroll in AkebiaCares and that I want Akebia to provide me with Patient Support. By signing below, I also authorize the Centers for Medicare & Medicaid Services to disclose Medicare eligibility information to Akebia.

If I am applying for financial assistance, I also agree that Akebia can use the information provided on this form or otherwise provided by me directly or through My Providers (including my Social Security number, household information, and household income) to obtain credit reports about me from credit reporting agencies in order to verify the information, estimate my income, and determine my eligibility for financial assistance. Regardless of whether a credit report is obtained, Akebia has the right to require written proof of income (such as a Form 1040, Form W-2, or other documentation) from me in connection with a financial eligibility determination.

Opt-in to Receive Marketing Communications (optional): By checking this box, I authorize Akebia, and companies working with Akebia, to contact me regarding product and educational information, and for other opportunities, including, but not limited to, customer surveys. I understand that I am not required to provide this consent as a condition of receiving any Akebia medicine or services from Akebia.

I understand that I may opt-out of these communications at any time via the link/contact information available in all communications.

Please enter a patient or authorized patient representative name.
Relationship to patient
Please enter a patient or authorized patient representative signature.
Please enter a valid date.

§The authorized patient representative may not be the patient's healthcare professional.

F Prescriber information One or more fields have not been completed properly.

One or more fields have not been completed properly.
Please enter a first name.
Please enter a last name.
Please enter a valid prescriber NPI.
State*
Please select a state.
State*
Please select a state.
Please enter a contact person first name.
Please enter a contact person last name.
Please enter a title.
Please enter a valid contact number.
Please enter a valid contact fax number.
Please enter a valid email.
Contact location*
Please make a selection above.

G Healthcare professional signature for Benefits Verification Services One or more fields have not been completed properly.

One or more fields have not been completed properly.

I attest that I am involved in the care and treatment of the patient and that I am making the below certifications and acknowledgments in consultation with and on behalf of the patient's prescriber. By signing below, I certify and acknowledge that (1) the prescribed Akebia medication is medically necessary and is in the best interests of the patient identified on this form; (2) the information in this form is accurate and complete to the best of my knowledge; (3) I am submitting this form to AkebiaCares to enroll the patient in AkebiaCares; (4) I am aware that the submission of this form to AkebiaCares does not guarantee that the patient will be eligible for AkebiaCares; (5) services provided by or on behalf of Akebia and/or AkebiaCares do not include the provision of treatment or medical advice or replace the treatment and care provided by the patient's prescriber; (6) any service provided by or on behalf of Akebia and/or AkebiaCares is not made in exchange for any express or implied agreement or understanding that the patient's prescriber will recommend, prescribe, or use the prescribed Akebia medication or any other Akebia product, and any decision to prescribe the Akebia medication was, and in the future will be, based solely on the prescriber's determination of medical necessity; and (7) I have obtained the required authorizations from my patient to release the referenced medical and/or other patient information relating to my patient's treatment to Akebia and AkebiaCares.

Please enter a healthcare professional name.
Please enter a title.
Please enter a healthcare professional signature.
Please enter a valid date.

H Prescription information One or more fields have not been completed properly.

One or more fields have not been completed properly.

Please only complete the column in this section that pertains to the fulfillment method your patient will use to fill their prescription.

Pharmacy Dispense

Select medication*

AURYXIA® (ferric citrate) tablets

Please make a selection above.
Please enter a day supply.
Please enter no. of refills.
Please enter sig/directions.
Send Rx to*
Please make a selection above.

PAP or Starter/Bridge
Therapy Dispense

Select medication*

AURYXIA® (ferric citrate) tablets

Please make a selection above.
Please enter a quantity.
Please enter no. of refills.
Please enter sig/directions.
Ship to*
Please make a selection above.

Check to enroll in auto refill

Medication allergies?*
Please make a selection above.
Please enter medication allergies.
Please enter current medications.

I Prescriber signature One or more fields have not been completed properly.

One or more fields have not been completed properly.

I attest I am responsible for the care and treatment of the patient and that I am making the certifications and acknowledgments outlined in Section F.

Please enter a prescriber name.
Please enter a valid prescriber SLN.
Please enter a prescriber signature.
Please enter a valid date.

For details about how we collect and use personal information, including applicable U.S. state privacy rights and notices for California residents, please visit https://akebia.com/privacy-policy/ .