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Prescription and Insurance Coverage Research Form PATIENT CONSENT PATIENT INFORMATION By signing below I certify that I have obtained a valid consent from the patient listed on this form authorizing me to release the patient s protected health information to Auxilium Pharmaceuticals Inc. and its contractors as necessary to obtain insurance coverage and payment for .

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g. clostridium histolyticum also is approved for the treatment of moderate to severe cellulite in the buttock. This is considered a cosmetic use and therefore not covered under the medical benefit.

The dose of ® is 0.58 mg per injection into a palpable cord with a contracture of a metacarpophalangeal (MP) joint or a proximal interphalangeal (PIP) joint. Each vial of ® and sterile diluent should only be used for a single injection.

For Open Drug Formularies, ® will be fully covered.

For more information, see helpful tips and reminders or call Endo Advantage at 1-877- (1-877-942-3539), Monday through Friday, from 9:00 AM to 8:00 PM ET. NOTE: Insurers may require you to use a specific acquisition method. NOTE: This form is only needed for "buy-and-bill" reimbursement.

Pain. Although is not uncomfortable to receive, some patients have significant pain for up to 48 hours after the injection, with rare patients having discomfort beyond this period. is more painful to receive, likely due to the volume of fluid, but is not significantly painful thereafter.

Results: Success was achieved in 36 of 47 treated joints (76.6%) after a single injection. There were 2 recurrences in 32 joints at 30-day follow-up (6.2%) and no recurrences in 17 joints available at 6-month follow-up.

Pain. Although is not uncomfortable to receive, some patients have significant pain for up to 48 hours after the injection, with rare patients having discomfort beyond this period. is more painful to receive, likely due to the volume of fluid, but is not significantly painful thereafter.

® for the treatment of Peyronie's disease is only available through a restricted program called the ® Risk Evaluation and Mitigation Strategy (REMS) Program. For more information about the ® REMS Program, go to www.XIAFLEXREMS.com or call 1 877 313 1235.

Actual patient ~24 72 hours after ® injection. Actor portrayal. WHAT IS ®? ® is a prescription medicine used to treat adults with Dupuytren's contracture when a cord can be felt.

costs $3,300 an injection, so a full course of eight injections would cost about $26,000, in addition to a doctor's fee. Doctors already use less expensive drugs off-label to treat Peyronies, including injections of a generic blood pressure drug.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232