Adempas Riociguat Prescription Enrollment Form
This file contains the enrollment form for Adempas (riociguat) prescription and patient support program specifically for VA patients. The document includes contact information, prescription details, and important safety information related to Adempas. It serves as a guide for prescribers and patients alike to ensure proper initiation and management of Adempas treatment.
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How do I fill this out?
To fill out this form, start by providing the required patient contact information. Next, complete the prescription section with the appropriate diagnosis and prescribed dosage. Finally, ensure that the prescriber has signed the document before submission.
How to fill out the Adempas Riociguat Prescription Enrollment Form?
1
Gather all necessary patient information.
2
Fill in the contact and diagnosis details accurately.
3
Complete the prescription section with required dosages.
4
Ensure the prescriber signs the document.
5
Submit the completed form as directed.
Who needs the Adempas Riociguat Prescription Enrollment Form?
1
Prescribers who need to prescribe Adempas for their patients.
2
Patients enrolled in the Adempas REMS Program for treatment initiation.
3
VA pharmacies processing Adempas prescriptions.
4
Healthcare providers managing pulmonary hypertension.
5
Adempas program officials ensuring compliance and safety.
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What are the instructions for submitting this form?
To submit this form, fax the completed document to the designated VA Pharmacy or send it to the Adempas program at 1-855-662-5200. Prescribers should ensure that all required information is filled out accurately to prevent delays. It is advisable to keep a copy for your records before submission.
What are the important dates for this form in 2024 and 2025?
Important dates for the Adempas program enrollment include initial submissions required before starting treatment. It is essential for all parties involved to meet these deadlines to prevent any delays in therapy. Keeping track of this timeline is crucial for patient safety and treatment effectiveness.
What is the purpose of this form?
The Adempas Prescription Enrollment Form serves multiple essential purposes. Primarily, it ensures that all female patients and prescribers are enrolled in the Adempas REMS program, which is crucial for treatment safety. Additionally, it collects vital information needed for prescriptions, helping prescribers in accurate dosing and patient monitoring.
Tell me about this form and its components and fields line-by-line.
- 1. Patient First Name: The first name of the patient is required for identification.
- 2. Patient Last Name: The last name of the patient is needed alongside the first name.
- 3. Birthdate: The patient's birthdate is crucial for age verification.
- 4. Diagnosis Information: Specific ICD-10 diagnosis codes must be indicated.
- 5. Prescription Details: Information about prescribed medication doses and refills.
What happens if I fail to submit this form?
Failure to submit the form can lead to delays in treatment for patients requiring Adempas. Additionally, it affects the ability of prescribers to provide the necessary prescriptions as they would be out of compliance with the REMS program. Ensuring timely submission is essential for safety and effective care.
- Delay in Prescribing: Not submitting the form can postpone effective treatment for the patient.
- Regulatory Compliance Issues: Prescribers may face compliance issues with the REMS program.
- Medication Access Problems: Patients may struggle to access their medications if the enrollment is incomplete.
How do I know when to use this form?
- 1. New Patient Enrollment: Required for patients beginning treatment with Adempas.
- 2. Ongoing Treatment Verification: Used for verifying continued eligibility and safety for existing patients.
- 3. Emergency Prescription Situations: Needed for urgent situations to ensure quick patient access to medication.
Frequently Asked Questions
What is the purpose of this form?
This form is used for enrolling patients in the Adempas prescription program.
How can I edit this PDF?
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Is there a way to sign this form electronically?
Yes, you can add your electronic signature directly on PrintFriendly.
Can I share the PDF after editing?
Absolutely! Use our share feature to distribute the PDF easily.
What information do I need to fill out the form?
You need patient contact information, diagnosis details, and the prescriber's signature.
Are there any specific contraindications I should know?
Yes, consult the important safety information included in the PDF.
How do I submit the completed form?
You can fax the completed form to the mentioned number or submit it through VA pharmacies.
Who must enroll in the Adempas REMS program?
All prescribers and female patients must enroll prior to treatment.
What are the common side effects of Adempas?
Common side effects include headache, dizziness, and hypotension.
Where can I find more information about Adempas?
More information is available at the official Adempas website or the REMS program site.
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