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:

  1. Ask your patient to fill out the left-hand side of the Form (sections 1-3)
  2. You fill out the right-hand side of the Form (sections 4-6)
  3. Once completed, simply email or fax the form to RELiZORB Support Services at RelizorbOrder@asembia.com or 1-844-233-3146

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.

Ordering is easy

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.

Distributor Product Number
AmerisourceBergen 10177832
Cardinal (Drug Side) 5206982
Cardinal (Medical/Surgical Side) 100295
McKesson 3507662
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.

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This information is intended for
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