User Manual Q&AAnswer
Jan 14, 2025 - 08:14 PM
To complete the Bosentan Testing and Patient Counseling Reporting Form, follow these steps:
1. Fill in the Prescriber Information section with your first name, last name, NPI#, phone number, fax number, and email address.
2. Fill in the Patient Information section with the patient's first name, last name, date of birth (in MM/DD/YYYY format), zip code, and gender (select either Male or Female).
3. Determine if the patient is a Female of Reproductive Potential (as defined in the Prescriber Guide). Select either Yes or No.
4. Confirm Liver Test Completed: Check the box to confirm that a liver test has been completed for the patient.
5. Confirm Pregnancy Test Completed (for females of reproductive potential): Check the box to confirm that a pregnancy test has been completed for the patient.
6. Acknowledgement of Patient Counseling: Check the box to confirm that the patient has been counseled on the risks associated with bosentan treatment and the Bosentan REMS requirements.
7. Sign and date the form. Print your name below your signature.
8. Indicate whether the form is being submitted by the Prescriber Designee or the Prescriber.
Please note that a certified prescriber or prescriber designee may complete and submit this form on behalf of the certified prescriber of record. The certified prescriber of record is responsible for monitoring, evaluating, and managing each patient under their care.
For additional information or assistance, you can visit the website www.BosentanREMSProgram.com or call the Bosentan REMS at 1-866-359-2612.
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