Endo Advantage Xiaflex Form

Endo Advantage Xiaflex Form - ENROLLMENT IN PROGRAM By using this Product including the Software and Hardware defined below Licensee enrolls in the ENDO Advantage license as described below to use the Product solely for the purpose of tracking ENDO Pharmaceuticals Inc Endo products and inventory and for certain benefit investigation and fulfillment services if

Prescription and Benefits Investigation Form Phone 877 XIAFLEX 877 942 3539 Fax 1 877 909 2337 Please complete this form in its entirety to ensure timely processing of the Benefit Investigation I Patient Authorization to Share Health Information

Endo Advantage Xiaflex Form

Endo Advantage Xiaflex Form

Helpline Fax Cover Sheet Healthcare professionals (HCP)/office staff can use this sheet to request assistance from Endo Advantage™. Benefits Investigation Form Use this form to initiate benefits investigation. Letter of Medical Necessity Sample letter for you to reference when drafting your request for coverage of injections for treatment.

1 800 939 3348 fax Acquiring XIAFLEX Quick tips for your practice Learn how Endo can support your office staff to obtain XIAFLEX Benefits Investigation Endo Advantage can conduct a benefits investigation for your patient Download these forms and resources to assist with access and reimbursement for XIAFLEX Office Administration Handbook

Prescription And Benefits Investigation Form XIAFLEX

Acquisition support video series Overview An overview of the XIAFLEX acquisition process and how Field Reimbursement Managers and Endo Advantage can support you Endo Advantage An introduction to the many ways Endo Advantage supports you during the acquisition process Specialty Pharmacy

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Endo AdvantageTM ID CLINICAL INFORMATION Anticipated initial injection Date Diagnosis Zip ICD 10 Patient Assistance Program Application PHYSICIAN CERTIFICATION

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XIAFLEX is indicated for the treatment of adult patients with Dupuytren s contracture with a palpable cord XIAFLEX is indicated for the treatment of adult men with Peyronie s disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy DOSAGE AND ADMINISTRATION

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Complete and offer a Service Examine Form by fax it to 1 877 909 2337 OR submit to form online through the Endo Advantage portal You cans enroll respective training for the Endo Advantage portal to automate benefits substantiation also to schienenweg your patient s status

XIAFLEX is a prescription medicine used to treat adults with Dupuytren’s contracture when a “cord” can be felt. It is not known if XIAFLEX is safe and effective in children under the age of 18. Click for full Prescribing Information , including Medication Guide .

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My signature below certifies 1 that the person named on this form is my patient and that XIAFLEX Please send this completed form to Endo Advantage Patient Assistance Program Address 6000 Park Lane Pittsburgh PA 15275 Phone 1 877 942 3539

Endo Advantage Xiaflex Form

Complete and offer a Service Examine Form by fax it to 1 877 909 2337 OR submit to form online through the Endo Advantage portal You cans enroll respective training for the Endo Advantage portal to automate benefits substantiation also to schienenweg your patient s status

Prescription and Benefits Investigation Form Phone 877 XIAFLEX 877 942 3539 Fax 1 877 909 2337 Please complete this form in its entirety to ensure timely processing of the Benefit Investigation I Patient Authorization to Share Health Information

Clinical Data XIAFLEX collagenase Clostridium Histolyticum