Patient Referral Benefit Support Form

Transcription

Patient Referral Benefit Support Form
Patient Referral Benefit Support Form
❏ Benefit Investigation
❏ Personalized Pharmacy Support
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Phone (855) 33 MEDAC (855-336-3322)!
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Patient Information
! !First Name: ________________________________ MI: ______ Last Name: ____________________________ Sex: ❏ M ❏ F
!
Email: ______________________________________________ SSN: __________________ DOB: _____________________
Address: _______________________________________________________________________________________________
! City: _____________________________________________________________ State: _______________ Zip: ___________
!
Preferred Phone: _____________________________________ Alternate Phone: ___________________________________
Allergies: _______________________________________________________ Diagnosis Code: __________________________
! Other Medications: _______________________________________________________ Prior Oral Methotrexate: ❏ Yes ❏ No
!
Insurance Information (*Required)
! Does patient have insurance: ❏ Yes
!
❏ No
(Please include front/back of insurance card)
*Prescription Drug Insurer:____________________________ *Rx Insurance Phone: ___________________________________
*Group #: ____________________*PCN #: ____________ *Bin #: __________
*ID #: ________________________________
! Primary Medical Insurance: ______________________________________
Cardholder Name: __________________________
Relationship to Cardholder: ❏ Self ❏ Spouse ❏ Other ID #:____________
Group #: _____________ Phone: ______________
Secondary Medical Insurance: ___________________________________
Cardholder Name: _________________________
! Relationship to Cardholder: ❏ Self ❏ Spouse ❏ Other ID #: ___________
Group #: _____________ Phone: ______________
!
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Office Use Only
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Physician Information (For home delivery, fax or attach a prescription with dosage, no. of refills and list of current medications)
! Physician Name: __________________________________________________ Specialty: ____________________________
NPI #: _________________________ State License #: ___________________ Tax ID #: _____________________________
! Practice Name: _________________________________________________________________________________________
! Address: ______________________________________________________________________________________________
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City: _____________________________________________________________ State: ________________Zip: ___________
Phone: _________________________________________ Fax:
_________________________________________________
! Office Contact Name: _______________________________________ Contact Phone: _______________________________
Prescribing Information
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Rasuvo Strength: ❏ 7.5 mg ❏ 10 mg ❏ 12.5 mg ❏ 15 mg ❏ 17.5 mg ❏ 20 mg ❏ 22.5 mg ❏ 25 mg ❏ 27.5 mg ❏ 30 mg
®
I authorize RxCrossroads to be my designated agent and to act as my business associate (as defined in 45 CFR 160.103) to use, disclose and receive any protected health information
(as defined in 45 CFR 160.103) (“PHI”) about any of my patients referred to the CORE Connections Program (“Patients”), including exchanging such information with pharmacies, insurers,
and nurse agencies/coordinators as needed to perform the following services for me: (i) obtain any benefits information about my Patients for the purpose of determining the Patient’s
insurance coverage for Rasuvo; (ii) submission of necessary documentation to support Prior Authorization and Pre-Determinations for my Patients coverage for Rasuvo; (iii) perform
adherence or compliance calls to my Patients related to Rasuvo treatment. RxCrossroads may also use and disclose such PHI to assist me with other functions related to my treatment
and as otherwise permitted or required by law. As my business associate, RxCrossroads is required to comply with the applicable requirements of 45 CFR 164.504(e)(2)(ii)(A) through
(I) and 45 CFR 164.314(a)(2)(i)(A) through (C) regarding business associates, and agrees that it will safeguard any PHI that it obtains on my behalf and will use and disclose this information
only as permitted herein. RxCrossroads acknowledges that if it materially breaches its obligations as stated herein, I may terminate its services as stated above and this agreement.
Physician Signature: _______________________________________________
Date: ______________________________
Fax a completed form and prescription to (800)481-3325
RxCrossroads Pharmacy NABP: 1827104 NPI: 1942398995
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