Get the free Synagis Enrollment Form

This document is an enrollment form for the Synagis program, used for patients at risk from Respiratory Syncytial Virus during the 2012-2013 season. It collects patient and prescriber information,

How to fill out synagis enrollment form

How to fill out Synagis Enrollment Form

1. Obtain the Synagis Enrollment Form from the healthcare provider or online.
2. Fill out the patient information section with accurate details, including the patient's name, date of birth, and insurance information.
3. Provide the referring physician's information, including name, contact details, and address.
4. Complete the clinical information section, detailing the medical history relevant to the need for Synagis.
5. Check the eligibility criteria to ensure the patient qualifies for Synagis treatment.
6. Sign and date the form where required, confirming that all provided information is correct.
7. Submit the completed form to the designated healthcare provider or insurance company as instructed.

Who needs Synagis Enrollment Form?

1. Infants born prematurely (less than 28 weeks' gestation).
2. Children under two years old with certain chronic lung diseases or congenital heart disease.
3. Patients with significant risk factors for respiratory syncytial virus (RSV) infection.

People Also Ask about

How do you qualify 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.

What is SYNAGIS used for?

SYNAGIS is a prescription medication that is injected (50 mg and 100 mg) in certain children to help prevent serious lung disease caused by respiratory syncytial virus (RSV).

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.

Who qualifies for RSV vaccine?

The cost for Synagis (100 mg/mL) intramuscular solution is around $1,910 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.

How much does Synagis cost in the US?

SYNAGIS® (palivizumab) may be covered under a patient's pharmacy or medical benefit. Sometimes SYNAGIS is covered under both benefits, or by more than 1 plan, depending on the patient's insurance. To ensure timely approval for SYNAGIS, collect all prescription and medical benefit information for appropriate patients.

For pdfFiller’s FAQs

What is Synagis Enrollment Form?

The Synagis Enrollment Form is a document used to enroll patients for Synagis, a medication that helps prevent respiratory syncytial virus (RSV) infections in high-risk infants and children.

Who is required to file Synagis Enrollment Form?

Healthcare providers prescribing Synagis for eligible patients are required to file the Synagis Enrollment Form on behalf of these patients.

How to fill out Synagis Enrollment Form?

To fill out the Synagis Enrollment Form, providers need to complete sections that request patient demographics, medical history, and insurance information, while ensuring all required fields are accurately filled.

What is the purpose of Synagis Enrollment Form?

The purpose of the Synagis Enrollment Form is to gather necessary information to facilitate the administration of Synagis and to ensure that high-risk patients receive the medication in a timely manner.

What information must be reported on Synagis Enrollment Form?

The Synagis Enrollment Form must report information such as patient name, date of birth, diagnosis, treatment history, insurance details, and signature from the guardian or patient.