u v Allergic Asthma Enrollment Form

Allergic Asthma Enrollment Form
Fax Referral To:
Phone:
Fax Referral To: 800-323-2445
Email
Referral
To:
Email Referral To: [email protected]
Phone: 800-237-2767
6 Simple steps to submitting a referral
u PATIENT INFORMATION
v PRESCRIPTION INFORMATION
(Complete the following or include demographic sheet)
Patient Name:
Address:
City, State, Zip:
Primary Phone:
Home
Cell
Work
Alternate Phone:
Home
Cell
Work
DOB:
Gender:
Male Female
E-mail:
Last Four of SS #:
Primary Language:
Prescriber’s Name:
State License #:
DEA #:
Group or Hospital:
Address:
City, State, Zip:
Phone:
Contact Person:
w INSURANCE INFORMATION
NPI #
Fax:
Phone:
Please fax copy of prescription and insurance cards with this form, if available (front and back)
x DIAGNOSIS AND CLINICAL INFORMATION
Diagnosis (ICD-9 or ICD-10):
493.
493.
Asthma
Asthma
ICD-10 Code & Description:
Patient Evaluation:
Height:
Allergies:
y
in/cm
Weight:
kg/lbs
PRESCRIPTION INFORMATION
MEDICATION
DOSE/STRENGTH
DIRECTIONS
Every 4 weeks dosing:
Xolair®
(Omalizumab)
150mg vial kit
Administer 150mg per dose subcutaneously every 4 weeks
Administer 300mg per dose subcutaneously every 4 weeks
Other: Administer __________________ mg per does
subcutaneously every 4 weeks
Please supply one vial of sterile water (10ml per vial) for every vial of Xolair® dispensed and
include ancillary supplies (syringe and needle, alcohol swabs).
Every 2 weeks dosing:
Administer 225mg per dose subcutaneously every 2 weeks
Administer 300mg per dose subcutaneously every 2 weeks
Administer 375mg per dose subcutaneously every 2 weeks
Other: Administer __________________ mg per dose
subcutaneously every 2 weeks
Supplies:
•
1 vial sterile water for injection (10 mL vial) for ever vial of Xolair® dispensed
•
Alcohol swabs
•
Flexible bandages 1” x 3”
•
3 mL Luer Lock injection syringe
•
NDL 18G x 1 & ½” Safety Glide needle for reconstitution
•
NDL 25G x 5/8” Safety Glide needle for subcutaneous injection
Send quantity sufficient for medication days supply.
QUANTITY
REFILLS
30-day
supply*
12
months
90-day
supply*
____
____ month
supply*
*Maximum
supply subject
to health
benefit limit
No supplies (The above supplies will be sent with shipment unless indicated.)
EpiPen®
Use as directed.
1
EpiPen® Jr.
Use as directed.
1
I certify that the rationale for Xolair® therapy for Allergic Asthma is necessary for this patient and I will be supervising the patient’s treatment accordingly.
Patient is interested in patient support programs
STAMP SIGNATURE NOT ALLOWED
z x___________________________________
DISPENSE AS WRITTEN
(Date)
Ancillary supplies and kits provided as needed for administration
x___________________________________
PRODUCT SUBSTITUTION PERMITTED
(Date)
IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is
received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event
should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Hepatitis C 022514