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Adempas Patient Enrollment and Consent Form 2025

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4.8 out of 5

181 votes

The Adempas Patient Enrollment and Consent Form is a document designed for enrolling patients in the Adempas Lab Coordination Program. It includes sections for patient information, female patient agreements regarding risks associated with Adempas, prescriber information, prescription details, and authorization for sharing medical information. The form emphasizes the importance of counseling female patients about potential birth defects and requires documentation of reproductive status. It also outlines the necessary steps for prescribing Adempas under an FDA-required Risk Evaluation and Mitigation Strategy (REMS).

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Click ‘Get Form’ to open the Adempas Patient Enrollment and Consent Form in the editor.
Begin by filling out the 'Patient Information' section. Enter the required fields marked with an asterisk, including First Name, Last Name, Birthdate, Gender, Address, and Preferred Phone. Ensure all information is accurate for effective communication.
For female patients, complete the 'Female Patient Agreement' section. Carefully read through the statements regarding counseling on risks associated with Adempas and provide your signature and date.
Proceed to 'Prescriber Information.' Fill in the prescriber's details such as First Name, Last Name, NPI, and Practice/Facility Name. This section is crucial for validating the prescription.
In the 'Prescription' section, specify the initial dose of Adempas along with any special instructions. Make sure to check whether home healthcare visits are authorized or if assessments will occur at the physician’s office.
Complete the 'Statement of Medical Necessity' by selecting appropriate diagnosis options and providing ICD-9 codes as necessary.
Finally, review all sections for accuracy before submitting. You can submit this form online or fax it directly to ensure timely processing.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (181 Votes)

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