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Patient Authorization and Notice of Release of Information (PAN) Form
The Patient Authorization and Notice of Release of Information (PAN) form is a three-page form that you must sign and date so that we have written permission to discuss your case with you, with your health care provider and with your health insurance plan.
Access Solutions Forms and Documents
| Description | Available Formats | |
|---|---|---|
| Patient Authorization and Notice of Release of Information (PAN) Form | Description | Write-in (302kb) Type-in (302kb) |
| Spanish Patient Authorization and Notice of Release of Information (PAN) Form | Write-in (173kb) |
If your doctor asks you to do this, you can complete this form and bring it to your next office visit in order to enroll with XOLAIR® Access Solutions™.
Additional Documents
| Available Format(s) | ||
| Medicare Appointment of Representative (AOR) | Description | View PDF (66kb) |
XOLAIR (Omalizumab) for Subcutaneous Use Indication
XOLAIR is indicated for adults and adolescents (12 years of age and older) with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with ICS. XOLAIR has been shown to decrease the incidence of asthma exacerbations in these patients. Safety and efficacy have not been established in other allergic conditions.WARNING
Anaphylaxis, presenting as bronchospasm, hypotension, syncope, urticaria, and/or angioedema of the throat or tongue, has been reported to occur after administration of XOLAIR. Anaphylaxis has occurred as early as after the first dose of XOLAIR, but also has occurred beyond 1 year after beginning regularly administered treatment. Because of the risk of anaphylaxis, patients should be closely observed for an appropriate period of time after XOLAIR administration, and health care providers administering XOLAIR should be prepared to manage anaphylaxis that can be life-threatening. Patients should also be informed of the signs and symptoms of anaphylaxis and instructed to seek immediate medical care should symptoms occur (see WARNINGS, and PRECAUTIONS, Information for Patients).
XOLAIR Safety Information
- XOLAIR should only be administered in a health care setting by health care providers prepared to manage anaphylaxis that can be life- threatening.
- XOLAIR should not be administered to patients who have experienced a severe hypersensitivity reaction to XOLAIR (see Boxed WARNING). XOLAIR should be discontinued in patients who experience a severe hypersensitivity reaction.
- Malignant neoplasms were observed in 20 of 4127 (0.5%) XOLAIR- treated patients compared with 5 of 2236 (0.2%) control patients in clinical studies of asthma and other allergic disorders.
- Patients should be given and instructed to read the Medication Guide before starting treatment and before each subsequent treatment.
- Patients receiving XOLAIR should be told not to decrease the dose of, or stop taking any other asthma medications unless otherwise instructed by their physician.
- The adverse reactions most commonly observed among patients treated with XOLAIR in clinical studies included injection site reaction (45%), viral infections (23%), upper respiratory tract infection (20%), sinusitis (16%), headache (15%), and pharyngitis (11%). These events were observed at similar rates in XOLAIR-treated patients and control patients.
Please see full Prescribing Information, including Boxed WARNING and Medication Guide, for additional Important Safety Information.
XOLAIR Access Solutions provides forms and documents in Adobe® Portable Document Format (PDF). In order to view PDF files, you must have Adobe® Reader® installed on your computer. If you don't have Adobe Reader or have an earlier version of Adobe Acrobat, you can download the most recent version for free at the Adobe Reader download site.
To open a PDF, simply click on the link. This will open the PDF in a new window. All PDFs can be printed or saved to your computer using the tools at the top of the PDF window. The “type-in” PDFs allow you to type directly into the form fields (instead of printing and filling out by hand).
