Xyrem Rems Program Form PDF Details

The Xyrem REMS Program Form is a document that provides information on the steps required to enroll in and participate in the Xyrem REMS Program. The form must be completed and signed by both the patient and their prescriber before they can receive Xyrem. The form includes important information on enrollment, risk management, and patient responsibilities. Patients who enroll in the program must comply with all requirements set forth by the program to ensure their safety. Participation in the Xyrem REMS Program is voluntary, but it is highly recommended for patients who are prescribed Xyrem.

QuestionAnswer
Form NameXyrem Rems Program Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesxyrem rems prescription form, xyrem rems form, xyrem forms, xyrem prescription form pdf

Form Preview Example

PATIENT ENROLLMENT FORM AND PRESCRIPTION FORM

Xyrem® (sodium oxybate) Oral Solution 500 mg/mL

Prescriber Information

Prescriber’s Name:

Office Contact:

 

 

 

 

Street Address:

 

 

 

 

 

City:

State:

Zip:

 

 

 

Phone:

Fax:

 

 

 

 

License Number:

DEA Number:

 

 

 

 

Email:

 

 

 

 

 

 

 

Patient Information

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

SS#:

 

 

 

 

 

 

 

 

 

 

DOB:

 

 

 

 

Sex:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

Best time to Contact:

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

Alternate Phone:

 

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

Insurance

 

 

 

 

 

 

 

 

 

 

Insurance Company Name:

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

Insured’s Name:

 

 

 

 

Relationship to Patient:

 

 

 

 

 

 

 

 

Identification number:

 

 

 

 

Policy/Group Number:

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

Prescription Card Attached:

 

 

 

 

 

 

Dosing

 

 

Total Nightly Xyrem Dose: _________gms

 

 

 

 

Xyrem 0.5 gms/mL

 

 

 

 

 

 

 

 

Split total nightly dose into two separate doses

First Dose: Take ______gms p.o. diluted in ¼ cup

(4 tbsp) of water at bedtime

Second dose: Then take _____gms p.o. diluted in

¼ cup (4 tbsp) of water again 2 ½ to 4 hours later.

Example dosing schedule: 6 gms total nightly dose = 3 gms Xyrem mixed in ¼ cup of water to take at bedtime and 3 gms

Xyrem mixed in ¼ cup of water to take 2 ½ to 4 hrs later. (NOTE: prepare both doses at the same time at bedtime)

Refi lls: 0 1 2 3 4 5 (circle one)

Total Quantity: ________ month supply

Special Instructions

(check boxes for initial prescription only)

I verify that the patient has been educated on Xyrem preparation, dosing, and scheduling (required)

I verify that the patient has received his/her own copy of the Patient Success Program Materials (optional)

Xyrem is medically appropriate for this patient.

Prescriber Signature (required) ____________________________________Date ___/___/_____

Fax completed form to Xyrem Success Program (toll-free) 1-866-470-1744

For information, call the Xyrem Team (toll-free) at 1-866-XYREM88 (1-866-997-3688)

MDPF-02 REV 0906

How to Edit Xyrem Rems Program Form Online for Free

If you need to fill out xyrem form, you won't have to download and install any kind of software - just use our online PDF editor. Our tool is consistently developing to provide the best user experience attainable, and that's thanks to our commitment to constant enhancement and listening closely to comments from users. This is what you will need to do to get started:

Step 1: Hit the "Get Form" button above on this webpage to access our tool.

Step 2: This editor lets you work with your PDF form in a range of ways. Change it by including any text, adjust what is originally in the document, and include a signature - all when it's needed!

As for the fields of this particular form, here is what you should do:

1. It is recommended to fill out the xyrem form accurately, so be careful when working with the sections that contain all of these blank fields:

Filling out part 1 in xyrem order form pdf

2. Your next step would be to fill out these particular blanks: emaN sderusnI, Identifi, rebmun noitac, tneitaP ot pihsnoitaleR, rebmuN puorGyciloP, Prescription Card Attached Yes No, Dosing, Total Nightly Xyrem Dose gms, Xyrem gmsmL Xyrem gmsmL, Split total nightly dose into two, First Dose Take gms po diluted in, Second dose Then take gms po, Example dosing schedule gms total, Refi lls circle one, and Total Quantity month supply.

Stage no. 2 for filling in xyrem order form pdf

Be very mindful while completing Identifi and tneitaP ot pihsnoitaleR, because this is the section where many people make mistakes.

3. Your next step will be easy - complete all the empty fields in I verify that the patient has, check boxes for initial, Xyrem is medically appropriate for, Prescriber Signature required Date, Fax completed form to Xyrem, tollfree, For information call the Xyrem, and MDPF Rev to conclude this part.

Completing part 3 of xyrem order form pdf

Step 3: Ensure the information is right and then simply click "Done" to complete the process. Create a 7-day free trial subscription at FormsPal and obtain direct access to xyrem form - downloadable, emailable, and editable inside your personal account. We don't share the details that you type in whenever working with documents at our site.

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