Get Lemtrada Rems Patient Authorization And Baseline Lab Form

Completing the LEMTRADA REMS Patient Authorization and Baseline Lab Form online is an essential step in facilitating the treatment process. This guide will provide you with clear and structured instructions to ensure that every section is filled out accurately and promptly.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your digital editor.
2. Begin by entering the prescriber information. Fill in the 'Name (Last, First)', 'Office Phone Number', 'Address', 'City', 'State', 'ZIP Code', and 'Prescriber LEMTRADA REMS Program Identification Number'. Ensure all fields marked with an asterisk (*) are completed as they are mandatory.
3. Next, proceed to the patient information section. Input the 'Name (Last, First)', 'Patient LEMTRADA REMS Program Identification Number', and 'Date of Birth (MM/DD/YYYY)'. Remember to fill in all required fields marked with an asterisk (*).
4. In the authorization and baseline labs section, indicate whether you authorize LEMTRADA treatment for the patient by selecting 'Yes' or 'No'. Then, attest whether the necessary baseline laboratory testing has been completed within 30 days prior to the treatment by selecting 'Yes' or 'No'.
5. Move on to the prescription information section. Check the appropriate option to indicate whether this is an initial course or a subsequent course of treatment. Provide the total number of vials required, ensuring your choice reflects the correct prescription requirements.
6. Finally, sign and date the form in the designated areas under the signature section. The prescriber signature is essential for the form's validity.
7. After filling out all sections, ensure you review the information for accuracy. Once confirmed, you can save changes, download, print, or share the completed form as required. Don't forget to fax it to the LEMTRADA REMS Program at 1-855-557-2478 or submit it online.

Complete your LEMTRADA REMS Patient Authorization and Baseline Lab Form online today for a streamlined treatment process.