OXERVATE Patient Enrollment Form INSTRUCTIONS Complete all pages of this form for each new prescription. Please Print. Please FAX completed form to Domp Connect to Care at 1.8884548488, phone 1.8333667387.
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How to fill out the Dompe OXERVATE Patient Enrollment Form online
Filling out the Dompe OXERVATE Patient Enrollment Form online is an essential step for patients seeking treatment. This guide provides clear, step-by-step instructions to help users navigate through the form with ease and ensure all necessary information is accurately provided.
Follow the steps to complete the enrollment form successfully.
- Press the ‘Get Form’ button to access the Dompe OXERVATE Patient Enrollment Form and open it in your preferred document editing tool.
- Begin by entering patient information, including the name, date of birth, address, preferred phone number, alternative phone number, and Social Security Number (last four digits). Make sure to indicate the best time to call.
- Provide details about the patient's insurance by selecting the appropriate primary and secondary insurance plans and filling in the policyholder information, including names, dates of birth, policy numbers, and insurance plan names.
- In the treatment information section, the prescriber must select the treated eye(s) and check all applicable ICD-10 codes. Additionally, fill in the product information for OXERVATE, directions for administration, and include the prescriber’s signature.
- Next, complete the patient support request section. Indicate the relevant support programs and ensure the patient's insurance benefits are thoroughly documented.
- In the patient authorization section, ensure the patient or guardian signs and dates the authorization form. Make sure that all conditions are understood, particularly around the sharing of health information.
- Finally, review all sections for accuracy and completeness. After ensuring all required fields are filled out, save your changes. You can download or print the form for faxing it to the designated number provided in the instructions.
Take the next step in your treatment by completing the Dompe OXERVATE Patient Enrollment Form online today.
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Does oxervate help dry eyes?
Oxervate (cenegermin) works to treat neurotrophic keratitis by helping the nerves in your eye grow and work properly. Can I use Oxervate (cenegermin) to treat other eye problems, like dry eye? No, Oxervate (cenegermin) must only be used for the treatment of neurotrophic keratitis as instructed by a provider.
How long is oxervate prescribed for?
Instill one drop of OXERVATE in the affected eye(s), 6 times a day at 2-hour intervals for eight weeks. To report ADVERSE REACTIONS, contact Dompé U.S. Inc. at 1-833-366-7387 or FDA at 1-800-FDA-1088 or .fda.gov/medwatch. Please see full Prescribing Information for OXERVATE.
How long does it take for Oxervate to work?
†In clinical trials, up to 72% of patients achieved complete corneal healing, defined as the absence of staining of the corneal lesion and no persistent staining in the rest of the cornea after 8 weeks of OXERVATE treatment.
What are the side effects of Oxervate?
Eye discomfort, pain, redness, watery eyes, or temporary blurred vision may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly. Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects.
What is the benefit of Oxervate?
The active substance in Oxervate, cenegermin, is a copy of a human growth factor called nerve growth factor. When given as eye drops to patients with neurotrophic keratitis, cenegermin helps restore some of the normal healing processes in the eye and repair damage to the eye's surface associated with the condition.
Does oxervate improve vision?
Oxervate improved corneal sensitivity, vision in stage 1 neurotrophic keratitis.
How do you get Oxervate?
How do I get OXERVATE? OXERVATE is a prescription medication and you will need to speak with your doctor to determine if it is right for you. If you are prescribed OXERVATE, the Dompé Connect to Care program is here to help you access the medication.
Does Oxervate need to be refrigerated?
Note: After the vial adapter is connected to the vial, OXERVATE can be stored in the refrigerator between 36°F to 46°F (2°C to 8°C) for up to 12 hours. If needed, the OXERVATE with the connected vial adapter may be stored at room temperature up to 77°F (25°C).
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