Xyrem prescription form 2025

1. Click ‘Get Form’ to open the xyrem prescription form in the editor.
2. Begin by filling out the Prescriber Information section. Enter the prescriber’s name, office contact details, address, phone, fax, license number, DEA number, and email.
3. Next, complete the Patient Information section. Provide the patient's name, social security number (SS#), date of birth (DOB), sex, address, contact numbers, and email.
4. In the Insurance section, input the insurance company name and phone number. Fill in the insured’s name, relationship to patient, identification number, and policy/group number. Indicate if a prescription card is attached.
5. For Dosing instructions, specify the total nightly Xyrem dose and split it into two doses. Clearly indicate each dose amount and ensure you follow the dilution instructions provided.
6. Check any applicable boxes under Special Instructions regarding patient education on Xyrem preparation and materials received.
7. Finally, ensure that you sign and date the form before submitting it via fax to the Xyrem Success Program.

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