Qutenza

Phone: 855-802-8746 | Fax: 855-454-8746

My Qutenza Coverage Enrollment

Welcome to the My Qutenza Coverage enrollment page. To submit an enrollment request, please fill in as much detail as possible about your practice and doctors. All fields marked with an asterisk (*) below are required. All information provided will be stored in your browser session and will be automatically deleted when your session expires ( after there has been no action in at least 15 minutes). My Qutenza Coverage uses the information you submit on this form to process your enrollment request. By clicking on the "Submit Enrollment" button below, you agree that the information you provide will be governed by our site Privacy Policy.

NPI

Input a provider or practice NPI and we'll see if we can find the rest!

Practice

User

Prescriber

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M-QZA-US-11-20-0029 12/2020

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