PATIENT ENROLLMENT FORM

Don't forget, you must first prescribe STIOLTO RESPIMAT to successfully enroll your patient in the program.

Step 1 Fax a hard-copy Rx to 877-816-5528 or ePrescribe to Eagle Pharmacy, NPI# 1487905840.

Step 2 Fill out the form below and your patient will immediately start receiving the benefits of the STIOLTO PROMISE Program.




By checking here, I would like to receive a one-on-one session with a Respiratory Therapist (RT) or Registered Nurse (RN) at no charge on behalf of the STIOLTO Promise program and BIPI. I agree to be contacted by phone at the phone number listed above in order to schedule my session and to receive a voicemail if I am not available.
By checking here, I am authorizing Boehringer Ingelheim Pharmaceuticals, Inc. and its agents (Collectively, "BIPI") and Eagle Pharmacy to use this information to enroll me in the Program and provide me with Program services. I also understand and agree to be contacted by Eagle Pharmacy at the phone number listed above in order to complete your enrollment, and for Eagle Pharmacy to leave a voicemail if I am not available.


Please have the patient read the following HIPAA Authorization

The STIOLTO PROMISE Program (the "Program") offers patient support services such as medication home delivery, in-home support services, and adherence support. The Program is administered by Eagle Pharmacy and BIPI.

By signing below, you are authorizing each of your physicians, pharmacists, and other health care providers (collectively, "Health Care Providers") to use and disclose to Eagle Pharmacy and its agents your medical information and any other information necessary for your participation in the Program. You are also authorizing Eagle Pharmacy to disclose all such information to BIPI.

Eagle Pharmacy will receive and use this information to enroll you in the Program and provide Program services to you. BIPI may also use this information for purposes of the Program and/or to communicate with you about other BIPI products or services.

You also understand and agree to the following:

  • Once your information has been disclosed to Eagle Pharmacy and BIPI, federal privacy laws may no longer protect the information from further disclosure.
  • You do not have to sign this Authorization. Refusing to sign will not affect your treatment by your Health Care Providers or insurance coverage in any way. However, you will not be eligible to participate in the Program.
  • This Authorization will remain in effect until you are no longer participating in the Program, at which time it will expire.
  • You may cancel this Authorization at any time by contacting (877) 460-4611. If you cancel, your Health Care Providers and Insurers will not make further disclosures of your information, but Eagle Pharmacy and BIPI will still be able to use and disclose information they have already received. If you cancel, you will no longer be eligible to receive Program services.
  • You are entitled to a copy of the Authorization.


PATIENT, by typing your full name in this box and providing either an email address or phone number, this serves as your electronic signature and acceptance of this HIPAA authorization.


Please see Important Safety Information provided to you in the STIOLTO Promise Welcome Kit or visit STIOLTO.com. Please see accompanying Prescribing Information, including boxed WARNING, Medication Guide, and Instructions for Use, for STIOLTO RESPIMAT.