Spravato Patient Enrollment Form
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This Form Is Intended Only For Use By Outpatient Medical Ofices Or Clinics, Excluding Emergency Departments.
Spravato withme savings program patient assignment of benefits. This form is intended only for use by outpatient medical ofices or clinics, excluding emergency departments. Web patients treated in outpatient healthcare settings (e.g., medical ofices and clinics) must be enrolled in the program. Complete and submit the spravato® rems outpatient healthcare setting enrollment form to the rems.
This Section Is To Be Completed By The Patient.
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Web learn about spravato withme, a program helping patients with access and affordability, and enroll your patients now. Web patient data patient name: Enroll your patients in the spravato withme program. Please see additional important safety information in this.
Learn how to minimize delays in the approval process. Complete and submit the spravato® rems outpatient healthcare setting enrollment form to the rems. Web patient data patient name: See full prescribing & safety info, including boxed. Web to enroll in rems online, you must create an online account by filling out and submitting the registration form at spravatorems.com.†.