Get Trokendi Xr Service Request Form Trokendi Xr Fax

The Trokendi XR Service Request Form is essential for initiating the process of obtaining Trokendi XR, an extended-release formulation of . This guide provides step-by-step instructions to help users accurately complete the form online.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to download the Trokendi XR Service Request Form and open it in your preferred editor.
2. Begin by entering the patient information in Step 1. Fill in the patient's name, sex, date of birth, and address. Ensure that the contact numbers for the patient and their parent or legal guardian are accurate. If applicable, provide health insurance details and attach copies of the insurance cards.
3. Move on to Step 2, where you must read and sign the patient authorization section. It is critical to understand what personal health information is being authorized for disclosure.
4. In Step 4, complete the RX information by documenting the patient's diagnosis and ICD-9 code. List any anticonvulsant medications that have been previously tried, including reasons for discontinuation. Also, record medications that the patient is currently taking, the dosages, and the drug strength of Trokendi XR. Indicate the prescribed quantity and provide detailed directions for use.
5. Finally, in Step 5, the prescriber must review the prescriber authorization. Ensure the prescriber signs and dates this section. Include their name, specialty, and contact information. Confirm that the form is accurate and complete before submission.
6. After completing the form, save your changes. You have the option to download, print, or share the completed form as necessary, ensuring it is ready for faxing to Supernus Support.

Complete the Trokendi XR Service Request Form online today to facilitate the prescription process.