Adempas Enrollment Form – Download Fillable PDF for Patients
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Adempas Enrollment Form |
Patient Support Program |
01 Pages |
PDF, Fillable PDF |
Adempas Enrollment Form
The Adempas enrollment form is an important document required for patients who need to access Adempas through the REMS program. This form verifies patient eligibility, confirms that all safety steps are understood, and ensures that both the prescriber and patient follow the REMS requirements. It also documents consent for counseling, pregnancy testing, and safe-use guidelines. If you need this form, you can download it or fill it out online on StartForms.health.
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Benefits of The Adempas Enrollment Form
Safety Rules Assurance
Adempas has specific safety measures due to pregnancy-related risks. The form verifies that the prescriber has provided the required counseling and that the patient understands the testing schedule, safe-use instructions, and ongoing monitoring expectations.
Accurate Reproductive Status Documentation
For female patients, the Adempas enrollment form includes a dedicated section to identify reproductive status. It helps determine whether pregnancy prevention measures, monthly pregnancy testing, or additional counseling are needed before, during, or after treatment.
Simplified Enrollment in REMS Program
Once the form is completed and submitted accurately, the patient is officially enrolled in the Adempas REMS program. It reduces delays and avoids the need for repeated requesting or missing information.
Key Section of The Adempas REMS Enrollment Form
Patient Details
This section includes the patient’s name, mailing address, phone number, and communication preferences.
Diagnosis & Medical Necessity
The prescriber documents the patient’s condition and confirms that Adempas is medically necessary.
Therapy Status
It indicates whether the patient is new to Adempas, continuing treatment, or restarting treatment.
Prescriber Details
Includes the prescriber’s name, NPI, practice details, contact numbers, and identifiers.
Prescriber Certification
The prescriber confirms that counseling, monitoring, and REMS requirements will be followed.
Patient Consent
The patient signs the form to confirm understanding of the risks, requirements, and commitment to follow REMS safety steps.
How To Complete The Adempas Enrollment Form?
Patient Information: Enter the patient’s full name, date of birth, gender, complete address, preferred phone number, preferred time to contact, and alternative contact details.
Statement of Medical Necessity: Indicate the appropriate medical diagnosis and medical necessity.
Female Patient Agreement: The patient or their guardian must sign and date the form to confirm understanding of risks, counseling, and REMS requirements.
Prescriber Information: Fill in the prescriber’s name, facility name, NPI number, state license number, and complete address.
Reproductive Status Details: Female patients must have their reproductive status documented. If of reproductive potential, they require pregnancy counseling and a routine pregnancy test.
Prescriber Authorization: The prescriber signs to confirm they will follow all REMS responsibilities.
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Frequently Asked Questions
What is the Adempas enrollment form used for?
It is mandatory because Adempas is available only through a REMS program. The form verifies that the prescriber has completed all required counseling and that the patient understands the risks, monitoring steps, and safety requirements.
Who completes the form?
Both the prescriber and the patient complete their respective sections. Female patients may need additional reproductive information.
Can a patient start Adempas treatment before the submission?
No. The REMS program requires that the Adempas form be fully completed, signed, and accepted before Adempas can be dispensed.
Can I submit this form online?
Of course, you can either submit it through fax or online through the official Adempas REMS website.
Can the information be updated later?
Yes, you can make changes later, such as contact information, treatment status, or reproductive details.
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