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This document is an enrollment form for the Little Lungs and Synagis program, requiring patient and parental information, insurance details, and a risk assessment for the patient's health status.
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How to fill out Little Lungs and Synagis Enrollment Form: 2011 – 2012
01
Begin by collecting personal information such as the child's name, date of birth, and insurance details.
02
Fill in the family contact information, including address and phone number.
03
Indicate the child's medical history, specifically any conditions that may require Synagis.
04
Provide information about the healthcare provider, including the doctor's name and contact details.
05
Review the eligibility criteria and confirm that the child meets the necessary conditions.
06
Sign and date the form to certify that the provided information is accurate.
07
Submit the form to the appropriate healthcare provider or organization.
Who needs Little Lungs and Synagis Enrollment Form: 2011 – 2012?
01
The Little Lungs and Synagis Enrollment Form is needed by families of infants or young children who are at high risk for respiratory syncytial virus (RSV) and need Synagis (palivizumab) for prevention.
02
Healthcare providers who are managing high-risk pediatric patients also need this form to ensure proper enrollment.
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People Also Ask about
Is Synagis covered by insurance?
The SYNAGIS Copay Assistance Program helps eligible patients with commercial insurance manage out-of-pocket costs. Patients may save up to a maximum of $6,000 per calendar year. DISCLAIMER: The SYNAGIS Copay Assistance Program only covers the cost of the medication, not the cost of administration.
Who qualifies for Synagis?
SYNAGIS gives babies who are born prematurely (at or before 35 weeks, and who are 6 months of age or less at the beginning of RSV season) the virus-blocking antibodies they lack, helping protect their vulnerable lungs from RSV.
How much is Synagis out of pocket?
The cost for Synagis (100 mg/mL) intramuscular solution is around $1,954 for a supply of 0.5 milliliters, depending on the pharmacy you visit.
How much is RSV shot without insurance?
Pediatric/VFC vaccine price list VaccineBrandname/ TradenamePrivate Sector Cost/ Dose Respiratory Syncytial Virus (RSV) BeyfortusTM (50mg) $556.132 Respiratory Syncytial Virus (RSV) Abrysvo™ $306.80 Rotavirus, Live, Oral, Pentavalent F RotaTeq® $98.818 $98.81840 more rows • May 1, 2025
How much does a Synagis injection cost?
abbive Synagis Palivizumab 50mg Injection at ₹ 12000/vial in New Delhi ID: 26510263497.
Who is eligible for Synagis?
SYNAGIS gives babies who are born prematurely (at or before 35 weeks, and who are 6 months of age or less at the beginning of RSV season) the virus-blocking antibodies they lack, helping protect their vulnerable lungs from RSV.
How much does a Synagis injection cost?
abbive Synagis Palivizumab 50mg Injection at ₹ 12000/vial in New Delhi ID: 26510263497.
How much does Synagis cost?
The cost for Synagis (100 mg/mL) intramuscular solution is around $1,954 for a supply of 0.5 milliliters, depending on the pharmacy you visit. Quoted prices are for cash-paying customers and are not valid with insurance plans.
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What is Little Lungs and Synagis Enrollment Form: 2011 – 2012?
The Little Lungs and Synagis Enrollment Form: 2011 – 2012 is a document used for the enrollment of eligible infants and children at risk for severe respiratory syncytial virus (RSV) disease to receive the Synagis medication, which helps prevent RSV infections.
Who is required to file Little Lungs and Synagis Enrollment Form: 2011 – 2012?
Healthcare providers or caregivers of eligible infants and children at risk for RSV are required to file the Little Lungs and Synagis Enrollment Form: 2011 – 2012.
How to fill out Little Lungs and Synagis Enrollment Form: 2011 – 2012?
To fill out the Little Lungs and Synagis Enrollment Form: 2011 – 2012, complete all required fields with accurate information regarding the child's health, medical history, and eligibility criteria, and submit it to the designated healthcare provider or organization.
What is the purpose of Little Lungs and Synagis Enrollment Form: 2011 – 2012?
The purpose of the Little Lungs and Synagis Enrollment Form: 2011 – 2012 is to enroll at-risk infants and children for the administration of Synagis, ensuring they receive the necessary preventive treatment against RSV.
What information must be reported on Little Lungs and Synagis Enrollment Form: 2011 – 2012?
The information that must be reported includes the child's personal details, medical history, risk factors for RSV, and any other relevant health information to determine eligibility for the Synagis treatment.
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