Select one of the options below as your preferred method for receiving the forms:
Select the forms you'd like to receive via email. Then, provide your email address and click "Submit" to get them sent directly to your inbox.
After downloading, you will then submit it to the XYWAV and XYREM REMS by e-mail, fax, or mail. For best results, please use Adobe Acrobat to fill out the forms prior to printing.
Scan and Email to:
ESSDSPrescribers@express-scripts.com
OR
Fax to:
XYWAV and XYREM REMS
1-866-470-1744 (toll free)
OR
Mail to:
XYWAV and XYREM REMS
PO Box 66589
St. Louis, MO 63166-6589
Print the enrollment form to have your patient sign it in your office.
You can only Fax or Mail this form.
You can only Fax or Mail this form.
By using DocuSign, the XYWAV and XYREM REMS can ensure that your personal information can stay safe, secure, and protected.
If you begin patient enrollment online, your patient will receive an e-mail to complete their portions of the form, including an e-signature. Then, you will electronically submit the form to the XYWAV and XYREM REMS. Both you and your patient will be notified when enrollment in the program is successful.