Xywav Enrollment Form – Download Fillable PDF for Patients
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Xywav Enrollment Form |
Patient Support Program |
01 Pages |
PDF, Fillable PDF |
Xywav Enrollment Form
Starting treatment with Xywav or Xyrem requires proper enrollment in the official REMS (Risk Evaluation and Mitigation Strategy) program. This process ensures patient safety, meets regulatory requirements, and maintains clear communication between the patient, prescriber, and pharmacy. The Xywav enrollment form is the initial step for patients and healthcare providers, and completing it accurately helps avoid delays in starting treatment. To start the process quickly, download, complete, and submit the form.
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Benefits of The Xywav Patient Enrollment PDF Form
Patient Safety
The form confirms that the prescriber has counselled and acknowledged that the patient has been informed about the potential risks of Xywav and Xyrem, ensuring treatment starts with a clear understanding of safe use.
Insurance & Coverage Support
The Xywav enrollment form includes a dedicated section for insurance details and requires a copy of the patient’s prescription benefit card. This helps pharmacies process claims faster and avoid coverage delays.
Easy Submission
The form can be submitted online, by fax, email, or mail, giving flexibility and making it easier for prescribers and patients to complete the process without unnecessary interruptions.
Key Sections of The Xywav Enrollment Form?
1- Prescriber Details
The first section contains the prescriber’s information, including their name, address, DEA number, NPI, phone number, fax number, and office contact details.
2- Patient Information
It includes full name, DOB, gender, phone numbers, address, and email.
3- Caregiver Details
It provides the caregiver’s name, their relationship to the patient, and their contact number.
4- Insurance Information
Include details about the patient’s insurance coverage, such as policyholder name, insurer, Rx ID, PCN, BIN, etc.
5- Acknowledgement & Signatures
The last section requires signatures from the patient/caregiver and prescriber to confirm that counselling, consent, and compliance with REMS requirements have been met.
How To Complete The Fillable Xywav Enrollment Form?
Prescriber Information: The prescribing doctor must fill in their complete name, DEA number, NPI number, street address, city, state, ZIP code, fax and phone number, and office contract details.
Patient Information: Write the patient’s name, complete address, date of birth, gender, contact details, email address, and caregiver details.
Insurance Information: Indicate whether the patient has prescription coverage. Also, attach the front and back copies of the insurance card(s), providing insurance details, such as policyholder name, date of birth, insurance company name, pharmacy name, BIN, PCN, and group ID.
Signatures: Both the patient/caregiver and prescriber must sign and date the form.
Download Xywav Enrollment Form PDF
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Frequently Asked Questions
What is the purpose of the Xywav enrollment form?
This form collects required information about the prescriber, patient, caregiver, and insurance and is used to start treatment with Xywav or Xyrem. Additionally, it confirms that counselling has taken place and ensures compliance with the REMS program.
Who needs to complete the form?
Patients starting Xywav or Xyrem, and their prescriber, must sign and date the form. The prescriber provides their details, such as DEA number, state license number, and contact number. While the patient or their caregiver provides personal, insurance, and acknowledgement details.
How can I submit the completed form?
- Online through the REMS website “http://www.xywavxyremrems.com/“.
- By email.
- By fax to 1-866-470-1744
- By mail to PO Box 66589, St. Louis, MO 63166-6589.
Does the form need to be completed again for refills?
No. The form is usually required only once at the beginning of the treatment. However, updates may be necessary if the patient’s information, insurance coverage, or caregiver details change.
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