Download Patient Enrollment Form for RELiZORB here
Getting your patient started with RELiZORB is easy. RELiZORB Support Services will be here every step of the way to help you, and to help your patient start and stay on RELiZORB under your direction.
You and your patient can work together to complete the Patient Enrollment Form; just follow these 3 easy steps:
Below is a link to a sample Letter of Medical Necessity to request approval for use of and subsequent payment for RELiZORB on behalf of your patient. The prescriber must modify the sample letter to be appropriate for the particular patient as the prescriber deems appropriate in his or her professional discretion.
For hospitals ordering RELiZORB, refer to the information below.
RELiZORB is supplied in boxes of 30 cartridges: 1 box = 30 cartridges.
The RELiZORB NDC* is 62205000020, and the UDI is 00862205000243.
|Cardinal (Drug Side)||5206982|
|Cardinal (Medical/Surgical Side)||100295|
|Morris & Dickson||245555|
*Third-party-derived code based on UDI.
For more information on how to order RELiZORB, contact RELiZORB Support Services at 1-844-632-9271.