Addyi Patient Provider Agreement Form

Patient Agreement Form Template Introduction This resource contains two standard patient agreement forms that can be used with patients who are starting long-term treatment with opioid analgesics or other liability exclusions: AAAS and EurekAlert! are not responsible for the accuracy of press releases published to EurekAlert! by contributing institutions or for the use of information on the EurekAlert system. Certification materials are available online under www.Addyi.com. To complete the certification process, prescribing physicians and pharmacists must send the completed knowledge assessment and registration forms to 844-694-3373 or by email to [email protected]. STRENGTHS OF PRESCRIPTION INFORMATION These highlights do not contain all the information necessary for the safe and effective use of ADDYI. See full prescribing information for ADDYI. addyi (Flibanserin) ADDYI Outpatient pharmacies must appoint a representative who completes training and knowledge assessments, trains its staff and advises any patient receiving flibanserin to give up alcohol. Hospital pharmacies have similar training requirements and should not dispense flibanserin for outpatient use. Sprout Pharmaceuticals has prepared a patient-supplier agreement to be signed by both parties. This agreement contains a break period for patients they can take home, which explains the risks of alcohol consumption during Addyi`s treatment and gives instructions on the dosage and management of dizziness, dizziness and fainting.

According to REMS conditions, healthcare providers must be trained and certified to prescribe Addyi. You should also explain the risks of syncopia and hypotension in patients and warn patients about interactions with alcohol. In addition, they must be sure that a patient gives up alcohol during treatment. Addyi REMS certification and registration documents can be accessed via www.Addyi.com. To be certified, prescribers and designated pharmacy agents must verify the addyi prescribing information and prescriber and pharmacy training documentation, complete a brief knowledge assessment and enroll in the Addyi REMS program. To complete the certification process, prescribers and pharmacists must send the completed knowledge assessment and registration forms to AddyiREMSEnroll@AddyiREMS.com by fax to 1-844-694-3373 or by email. For more information, please contact the Addyi REMS Support Center at 1-844-Addyi15 (1-844-233-9415). In addition, pharmacies must be trained and certified to deliver Addyi. Pharmacists can only fill prescriptions written by certified clinicians. You should also advise patients on the use of Addyi and emphasize the importance of avoiding alcohol while taking the drug….

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