REMS PROGRAM PATIENT ENROLLMENT FORM (sodium oxybate) oral solution 0.5 g/mL Fax completed form to REMS Program: 18664701744 (toll free) OR mail to: REMS Program, PO Box 66589,.
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How to fill out the Enrollment Form online
Filling out the Enrollment Form online is a straightforward process that ensures your information is captured accurately for the REMS program. This guide will help you navigate each section of the form, making it easier for you to complete it with confidence.
Follow the steps to successfully complete the Enrollment Form online.
- To obtain the Enrollment Form, click the ‘Get Form’ button. This will allow you to access the document in your editing platform of choice.
- Begin filling out the Patient Information section. Ensure that fields marked with an asterisk, which denote required information, are completed. Enter your first name, middle initial (if applicable), date of birth in the MM/DD/YYYY format, last name, gender, and contact numbers including primary, cell, and work phone.
- Continue with your address details. You will need to provide your full street address, city, state, and ZIP code. Ensure this information is accurate for processing.
- Next, move on to the Insurance Information section. Indicate whether the patient has prescription coverage by selecting 'Yes' or 'No.' If you select 'Yes,' you’ll need to attach a photocopy of the insurance identification card to the form.
- Fill in the policy holder’s name, date of birth, insurance company name, relationship to the patient, and insurance phone number. Complete any additional fields pertinent to the insurance plan, such as RxID, RxBIN, RxPCN, and RxGrp numbers.
- Proceed to the Prescriber Information section. Similar to the Patient Information, fill out the required fields including first and last name, DEA number, street address, phone number, city, state, ZIP code, office contact details, fax number, and NPI number.
- The form must have signatures to be processed. For the Patient section, the person enrolled (or their guardian) must sign and date the form to acknowledge understanding of the risks of . If applicable, print the guardian's name.
- For the Prescriber section, the prescriber must also provide a signature and date, indicating they have counseled the patient about the use of .
- Finally, review all the entered information for accuracy. Once confirmed, you can save your changes, download the completed form, and choose to print or share as necessary.
Begin filling out your Enrollment Form online today to ensure your participation in the REMS program.
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