Get Tirf Rems Access Patient-prescriber Agreement Form

Filling out the TIRF REMS Access Patient-Prescriber Agreement Form online is a crucial step for patients and prescribers involved in the TIRF REMS program. This guide provides clear and supportive instructions to help you navigate each section of the form effectively.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the prescriber information section. This includes entering your first and last name, DEA number, National Provider Identifier (NPI), and fax number. Ensure all required fields are filled in accurately.
3. Read through the acknowledgment statements carefully. These statements outline the responsibilities and understandings related to prescribing TIRF medicines. Check the box next to each acknowledgment as you confirm your understanding.
4. Proceed to the patient information section. The patient or their legally authorized representative must provide their first and last name, date of birth, phone number, state, and zip code. These details are essential for record-keeping and compliance.
5. If applicable, complete the patient representative section, including their signature, first and last name, and their relationship to the patient.
6. Review the Patient Privacy Notice thoroughly. Users have to acknowledge their understanding of how their health information will be shared within the TIRF REMS Access program. This protects both patients and their sensitive information.
7. Once all sections are completed and reviewed for accuracy, save your changes. You can then choose to download, print, or share the form as needed.

Complete your documents online today to ensure a smooth process for accessing TIRF medicines.