Get Prescriber Enrollment And Agreement Form. () Prescriber Enrollment And Agreement

The Prescriber Enrollment and Agreement Form is an essential document for healthcare professionals wishing to prescribe (). This guide provides step-by-step instructions to help users accurately complete the form to ensure compliance with the REMS Program.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering your prescriber details, including your full name, degree (MD, DO, etc.), and the date. Ensure that all names are spelled correctly.
3. Provide your professional affiliation by filling in the institution name if applicable. This information helps in identifying your practice setting.
4. Fill out your complete address, including street, city, state, and ZIP code. Accurate contact details are vital for communication regarding your enrollment.
5. Enter your telephone number and fax number. Make sure to include area codes to avoid any issues with contact.
6. Record your email address in the designated field since this will be the primary communication method for confirmation of your enrollment.
7. Complete your NPI number and specialty areas such as Epileptology, Pediatric Neurology, or other relevant fields.
8. Designate office contact names for any additional support. Include both first and last names.
9. Review the completed form thoroughly for any errors or omissions before submitting it.
10. Fax both pages of your completed form to the REMS Program at 1-877-742-1002 to finalize your enrollment.

Complete your Prescriber Enrollment and Agreement Form online and ensure you are certified to prescribe .