Get Addyi Rems Program Prescriber Enrollment Form - Needymeds

Completing the Addyi REMS Program Prescriber Enrollment Form is an essential step for prescribers who wish to participate in the program and prescribe Addyi. This guide provides a clear and straightforward approach to filling out the form online.

Follow the steps to successfully complete the Addyi REMS Program Prescriber Enrollment Form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering your first name and last name in the designated fields.
3. Next, input your practice name and address, ensuring to fill in the street address, city, state (ST), and zip code accurately.
4. Indicate your clinical specialty and select the appropriate professional title (MD, DO, NP, PA) from the options provided.
5. Fill in your NPI number and optionally your DEA number if applicable.
6. Provide your telephone number, fax number, and email address. Make sure to confirm your email in the designated field.
7. Select your preferred method of communication by checking the box next to either fax or email.
8. Once all fields are filled, review the information for accuracy.
9. You have the option to either fax the completed form to the Addyi REMS Program Support Center at 1-844-694-3373 or scan and email it to AddyiREMSEnroll@AddyiREMS.com.
10. Save changes or download the completed form if you need a copy for your records.

Complete your Addyi REMS Program Prescriber Enrollment Form online today to ensure your eligibility to prescribe Addyi.