RESOURCES

Our online enrollment form makes enrolling your patients in MyROCK ASSIST simple and straightforward.

Enroll your patients online now

If you prefer, download a paper enrollment form, work with your patients to complete the form and fax it to 1-833-635-1481 to begin the MyROCK ASSIST enrollment process.

Download English Enrollment Form

Download Spanish Enrollment Form

This template may be used to verify the patient’s need for medical treatment with REZUROCK^® (belumosudil) tablets.

Download English Letter of Medical Necessity

Download Spanish Letter of Medical Necessity

If a patient’s health insurance plan denies their request for prior authorization or coverage for REZUROCK, this templated letter may help with the appeal process.

Download English Letter of Appeal

Download Spanish Letter of Appeal

Find out how to order REZUROCK for your account.

Download Ordering Form

A guide to financial assistance and support for patients on REZUROCK.

Download Brochure

Find out which services patients may be eligible for by completing this form. Our MyROCK ASSIST Case Managers can determine which programs are available to patients.

For eligible patients with commercial or private insurance plans.