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Oxervate enrollment form

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The document is an OXERVATE™ Patient Enrollment Form that outlines the process for prescribing and enrolling patients in treatment with OXERVATE, an ophthalmic solution. It includes sections for patient information, treatment details, insurance information, and patient authorization for sharing health information with Dompé Connect to Care. The form must be completed by the prescriber and submitted via fax, along with necessary insurance documentation.

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2019	4.8 Satisfied (37 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a patient enrollment form?

A Hospital Patient Registration Form is a form template designed to streamline the process of collecting patient details before their stay in the hospital.

Does oxervate need to be refrigerated?

Note: After the vial adapter is connected to the vial, OXERVATE can be stored in the refrigerator between 36F to 46F (2C to 8C) for up to 12 hours. If needed, the OXERVATE with the connected vial adapter may be stored at room temperature up to 77F (25C).

How do you get Oxervate?

To begin the process, you simply sign the OXERVATE prescription enrollment form at your doctors office. Once insurance coverage has been determined, you can expect a welcome call from Domp CONNECT to Care within 24 hours after they receive the enrollment form from your doctor.

How much does oxervate cost?

Patients will usually go through 28 vials of Oxervate in a 4-week period, and the typical treatment course lasts for 8 weeks. The list price for Oxervate is $1,732 per vial, making the cost for a typical treatment course $96,992.

Where can I order oxervate?

Please add this phone number to your contacts so you dont miss this important call: 1-877-422-4412. Once approved for financial assistance, you will be contacted by Accredo, a specialty pharmacy, to coordinate your biweekly shipments of OXERVATE to your home or preferred shipping address.

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