Get the free Synagis Enrollment Form

This form is designed for the enrollment of patients requiring Synagis therapy for the prevention of Respiratory Syncytial Virus (RSV) during the 2012-2013 season. It captures necessary patient, prescriber,

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 the official website.
2. Fill in the patient's personal information such as name, date of birth, and insurance details.
3. Provide information about the patient's medical history, including any pre-existing conditions or allergies.
4. Indicate the healthcare provider's information, including name, contact number, and address.
5. Fill out dosage and administration details as advised by the healthcare provider.
6. Sign the form to confirm all information is accurate and complete.
7. Submit the completed form to the appropriate healthcare facility or insurance provider.

Who needs Synagis Enrollment Form?

1. Infants and young children at high risk for severe respiratory syncytial virus (RSV) infection.
2. Children with certain heart or lung conditions.
3. Premature infants who meet specific health criteria.

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 the Synagis (palivizumab) program, which provides preventative treatment for respiratory syncytial virus (RSV) in high-risk infants and children.

Who is required to file Synagis Enrollment Form?

Healthcare providers, such as pediatricians or specialists treating high-risk infants and children, are required to file the Synagis Enrollment Form to ensure patients receive the necessary treatment.

How to fill out Synagis Enrollment Form?

To fill out the Synagis Enrollment Form, healthcare providers must provide patient information, including demographic details, health history, and any specific criteria that qualify the patient for Synagis treatment.

What is the purpose of Synagis Enrollment Form?

The purpose of the Synagis Enrollment Form is to collect essential information to determine eligibility for Synagis treatment and facilitate the approval and administration of the drug to prevent severe RSV disease in vulnerable populations.

What information must be reported on Synagis Enrollment Form?

The information that must be reported on the Synagis Enrollment Form includes patient name, date of birth, medical history, weight, gestational age, and any other pertinent medical factors that support the patient's eligibility for Synagis therapy.