Submit a Medical Information Request to Intercept

MEDICAL INFORMATION REQUESTS

This form is intended for medical professionals only. If you are a healthcare professional and have a medical inquiry, complete this form and submit to Intercept Medical Information. This form is not intended to submit potential adverse events or product complaints. Contact 1-844-782-4278 to report a suspected adverse event or product complaint.

ALL FIELDS ARE REQUIRED UNLESS OTHERWISE NOTED

PERSONAL INFORMATION

First Name

Last Name

Degree

Other HCP

CONTACT INFORMATION

Phone Number

Address

Address Line 2 (Optional)

City

State

Province

Region

Zip Code

Postal Code

PREFERRED CONTACT METHOD(S)

Indicate how you would like the response to your inquiry delivered. Please select all that apply, including indicating if you would like to connect with your Medical Science Liaison (MSL). MSLs are your conduit to clinical research, important product information, and disease state education.

Fax Number

INQUIRY DETAILS

Select the product and disease state your unsolicited inquiry pertains to and explain your specific question.

Product

Disease State

Please explain your inquiry

In the event your request is for a publication reprint or the response to your medical information request necessitates the inclusion of a publication reprint, please select ONE of the following statements:

Please enclose any relevant reprints(s). I am aware that the value of the enclosed reprint(s) will be attributed to me and that Intercept will disclose a transfer of value associated with a reprint to the federal government in order to meet the requirements of the Patient Protection and Affordable Care Act ("ACA")†.Do not enclose any reprint(s) in the medical response. A list of citations in the response is sufficient.

†The ACA section entitled "Transparency Reports and Reporting of Physicians Ownership or Investment Interests," was enacted in 2010. This section of the ACA, also referred to as the Sunshine Act, mandates the reporting of the monetary value of clinical reprints provided to physicians. In addition, all transfers of value to US licensed physicians, including the value of reprints, will be published on the Centers for Medicare and Medicaid Services (CMS) Open Payments website annually.

More information about Open Payments can be found here.

DIGITAL SIGNATURE

I understand that checking this box constitutes my legal signature, that I am a healthcare professional, and I acknowledge that my medical information request has been unsolicited.