Physician Locator Application

Allows Doctors to apply to be included in the Doctor Locator database.

Step 1 of 7

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  • This field is for validation purposes and should be left unchanged.
  • Welcome! To be included in our Physician Directory for ILUVIEN patients, please fill out the form below.

    First, let’s see if you’re already in our system.
  • We didn’t find an NPI number matching this in the database. Please search by Physician last name.
  • This field is hidden when viewing the form
  • Next, we’ll identify the Practice Location where you would like to be added. Begin by giving us the Practice Location’s name and zip code. We’ll use this to see if the Practice already exists in our records.
  • Select which location to associate with the physician.
  • This field is hidden when viewing the form
  • Once you Submit this form, we will review and notify you if we need to verify any further information. Otherwise, your practice will appear in the ILUVIEN Provider Directory within 7-10 business days. Please review and agree to Terms on the next page before completing your application.
  • Terms of Participation

    By completing this form I represent that I am the physician requesting, or am a principal of the practice requesting, to be included in the Physician Locator, or that I otherwise have the authority to complete and submit this form on behalf of the physician or practice.

    Your name, address and other information that you provide to us will be used by Alimera Sciences, Inc. (“Alimera”) and the companies working with Alimera, pursuant to which your information may be made available to other healthcare providers, patients and consumers who wish to access your services. In order to be included within the ILUVIEN (fluocinolone acetonide intravitreal implant) 0.19 mg Provider Locator as a Healthcare Provider, you must be validly licensed (as required by state or federal law) and meet all of the following criteria: (A) Be able and willing to write prescriptions for pharmaceutical products, (B) Experienced in prescribing ILUVIEN and (C) Accepting new patients, provided they meet the requirements of your practice (e.g., accepted insurance types, etc.). You acknowledge that you received, read and understand the full Prescribing Information for ILUVIEN, including the directions for administration and use of the product. You are fully and solely responsible for the quality of care to be provided at your site of care.

    We may contact you by e-mail, postal mail or telephone to verify and update your profile, notify you as to any changes in eligibility criteria and assess your continued eligibility for the Provider Locator.

    Alimera will not share your information with anyone else except as described above or as required by law. Inclusion of your name and organizational information as part of our Provider Locator does not represent, and will not necessarily result in, any endorsement, referral or recommendation by Alimera and your agreement to be listed in the Provider Locator shall not be construed as an inducement or encouragement for the referral of patients or use of particular products. If you want to stop receiving this information, you may ask us to remove you from our contact list by calling 1-844-445-8843.
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