UroGen Account Set-Up Form

Download and complete the spreadsheet

Complete the spreadsheet in its entirety before uploading it.

Download Multi-Site Spreadsheet

Upload the completed spreadsheet*

Choose the completed Excel file from your device.

Upload Multiple Sites Spreadsheet No file selected

Street Address Line 1:*

Street Address Line 2 (optional):

City:*

State:*

ZIP Code:*

Contact Name:*

Contact Email:*

Contact Phone #:*

Number of Patients per month:*

Secondary Contact? (UroGen recommends adding a secondary contact.)

Yes

Secondary Contact Name:*

Secondary Contact Email:*

Secondary Contact Phone #:*

Billing Address

Same as Shipping

Street Address Line 1:*

Street Address Line 2 (optional):

City:*

State:*

ZIP Code:*

Contact Name:

Contact Email:

Contact Phone #:*

Potential Treatment Date: (Select 6 weeks from today if no patient identified.)*
(Potential treatment date will determine the timing of your ASF processing with the specialty distributor.)

Pharmacy Partner Needed?*

Yes

UroGen products require reconstitution prior to instillation per FDA-approved instructions for pharmacy

Reconstitution must occur in a USP 797- and 800–compliant pharmacy

UroGen has a qualified network of pharmacy partners available to meet your preparation needs

Network pharmacies will deliver admixture to your site of care per your direction (work with UroGen Support to ensure the product is delivered in advance of scheduled instillation)

Through the Drug Preparation Program, you can feel confident that preparation services for products will be accessible at a fair price ($400.00) where you want to use it, with potential discounts on UroGen products.

Delivery times will vary by Program pharmacy and provider locations, as well as courier times. UroGen makes no express warranty or representation of an exact delivery time, other than that, for accepted orders, prepared product will be delivered in advance of the scheduled time for patient instillation. Healthcare providers opting to use the Program are required to work closely with UroGen Support to coordinate patient scheduling and delivery. See UroGen Support limited warranty provisions at www.urogen.com/support/warranty.

I am authorized to make purchasing decisions on behalf of the above-listed Entity/Purchaser. By checking this box, on behalf of the above-listed Entity/Purchaser, I choose to receive prepared product from a UroGen Preparation Program pharmacy. I authorize and direct the shipment of my product purchase to a UroGen Preparation Program pharmacy selected by UroGen Support for product preparation and delivery in accordance with the UroGen Program offering. In conjunction with my election, I understand that I am eligible to receive a discount on my purchase, which will be reflected on my invoices, as will the Program costs. I understand that the above-listed Entity/Purchaser may be required to report any discounts received in accordance with the provisions of 42 C.F.R. 1001.952(h).

Account Type: (Select all that apply)

WAC (Wholesale Acquisition Cost) Account

New or Existing Account?*

If you have an existing account with Cardinal Health or Besse Medical/ Cencora please select existing and insert your account #
If you are filling out this form to set up a new account please select new account and fill out the below information.

New

Existing

NON-340B Account

New or Existing Account?*

New

Existing

340B Account

New or Existing Account?

New

Existing

Account

New or Existing Account?

New

Existing

New Account Info

Account Name:

Ship-to Address:

Ship-to DEA Number:

Global Location Number:

Any supporting documentation or licensure:

HIN:

Upload supporting documentation: (if available)

Name:*

Email:*

Date:*

By checking this box and completing this form, you agree to the following:*

To purchase UroGen products exclusively through your Besse Medical/Cencora or Cardinal Health Specialty Account
That the undersigned has the full power and authority to execute this agreement
To include a list of legal affiliates that will purchase UroGen products through Besse Medical/Cencora or Cardinal Health, including name, address, phone number, DEA number (if applicable), and state license number (if applicable) that has been attached to this form
To authorize Besse Medical/Cencora or Cardinal Health to share this information with UroGen Pharma and its partners to process orders for UroGen products on your behalf

BESSE MEDICAL/CENCORA OR CARDINAL HEALTH DISCLAIMER: Due to the detailed and thorough registration process, it may take approximately 15 business days for Besse Medical/Cencora or Cardinal Health to onboard your practice if you do not have an existing account. Once the account is established, you will be able to purchase specialty products and bill them to your Specialty Pharmaceutical Distribution (wholesale) account. You will be contacted to confirm details and complete a credit application during the account creation process. It is important for you to submit requests for additional documentation in a timely manner to avoid delays in setting up your account. Please ensure the shipping address provided on the form aligns with the licensure provided. For existing customers, a credit review and updated financial documents may be required. Besse Medical/Cencora or Cardinal Health will provide further instructions as needed.

PRIVACY NOTICE: For more information on what data we collect about you and how we use it, as well as information about the rights you may have under the California Consumer Privacy Act, please refer to our Privacy Policy and our California Supplemental Privacy Policy.

UroGen Account Set-Up Form

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UroGen Account Set-Up Form

Complete the two steps below

Site of Care

Billing Address

WAC (Wholesale Acquisition Cost) Account

NON-340B Account

340B Account

Account

New Account Info

UroGen Account Set-Up Form

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Complete the two steps below

Site of Care

Billing Address

WAC (Wholesale Acquisition Cost) Account

NON-340B Account

340B Account

Account

New Account Info

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