Makena Specialty Order Form

Transcription

Makena Specialty Order Form
Makena Specialty Order Form
Prescriber's Name:
MD / DO / NP / PA
Address:
City
Phone: 844-428-7387
Fax: 844-228-7387
State
Office Contact:
Office Contact:
Phone#
Phone#
NPI:
PATIENT INFORMATION
Send updates to
Fax
Fax#
Fax#
DEA:
Tax ID:
E-mail to _________________________
Patient's Name:
Zip
Text to Phone# _________________
DOB:
SS#
Address:
City
Home Phone:
State
Work or Cell:
Allergies:
Emergency Contact:
Sex: M____ F____ Wt:
Patient previously on treatment: Y N Date:
Primary Insurance:
Zip
Diabetic:
Ht:
African American
Caucasian
Native American
Other
Y
N
Asian
Latin/Hispanic
Pacific Islander
Insured:
Please send copy of Insurance Card
* Please include current patient medication list with referral *
DIAGNOSIS INFORMATION
Primary ICD-9:________________________________________________________________________________________________
Secondary ICD-9:___________________________________________ Other ICD-9 Code:__________________________________
CLINICAL INFORMAATION – Please complete in entirety.
CURREN PREGNANCY:
Current Gestational Age: _____ weeks _____ days
Date Recorded: _______________
Yes
No Is the patient pregnant with a singleton?
Yes
Yes
No Is the patient experiencing preterm labor?
No Does the patient have a cerclage?
Where will the Medication be administered?
Office
Home
Anticipated Start Date
Gravida:
Para:
0
0
1
1
2
2
3
3
Other: _______
Other: _______
Gestational Age of prior preterm birth: ______ weeks
Yes
No Has the patient had a previous spontaneous singleton
preterm birth (earlier than 37 weeks gestation)?
Yes
No Has the patient had any previous preterm birth?
If yes, please check indication(s) that apply:
If Home, please list CPT code requested ________
TREATMENT ARRANGEMENTS
OB HISTORY:
Multiple gestation
Fetal complications
Home
Doctors Office
Ship Meds:
Aureus
Teaching by:
Drs. Office
Maternal complications
Incompetent cervix
Lab in Box: Y or N
Other
Rx: Makena® (hydroxyprogesterone caproate injection)
250mg / mL multidose vial
Dispense 1 vial, followed by ____ refills for a complete
course of therapy
Sig: Inject 1mL IM each week
By
By signing
signingthis
this form
form and
and utilizing
utilizing our
our services,
services,you
youare
areauthorizing
authorizingAureus
SDHC and
and its employees
employeesto
toserve
serveas
asyour
yourprior
priorauthorization
authorization designated
designated agent
agentin
in dealing
dealingwith
with
medical and prescription insurance
insurance companies.
Prescriber Signature:
May Substitute
Dispense as Written
Date:
Form Form
# - Makena-090514
# - HEP-041514