Patient Enrollment Form Prescriber Information

Patient Enrollment Form
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Patient Information
*Patient Name:
*Date of Birth:
Address:
City:
*Daytime Phone:
Alternate Phone:
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Female
Male
State:
Zip:
Insurance Information
(Copy of insurance card[s] is acceptable in lieu of completing insurance information below)
*Primary Insurance Company:
*Policy Holder:
*Group #:
*Policy #:
*Provider ID:
Employer Group:
Phone #:
Secondary Insurance Company (if applicable):
Policy Holder:
Group #:
Policy #:
Provider ID:
Employer Group:
Phone #:
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3
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Prescription Insurance (if applicable):
Policy Holder:
RxBIN:
RxGRP:
Plan Code:
Phone #:
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Same as Prescriber
*Date:
Date:
Varithena Solutions Center™
BTG
Treatment Setting (please check one):
Physician Office (11)
Hospital Outpatient (22)
ASC (24)
Name:
Site of Service Tax ID:
Address:
City:
State:
Zip:
NPI:
Medicare PTAN:
Contact Person:
Contact Phone #:
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PATIENT AUTHORIZATION TO RELEASE, COLLECT, USE, AND DISCLOSE MEDICAL INFORMATION
If patient has not previously provided consent, please have patient review the following Authorization:
The Varithena Solutions Center™ can provide certain services to you and on your behalf during the
search for Varithena® therapy reimbursement and support services, including patient financial assistance.
The Varithena Solutions Center™ is operated by McKesson Specialty Arizona Inc., a contractor of
Biocompatibles, Inc., a BTG International group company; however, no BTG International group company
will have access to patient-specific health information. In order to provide these services, the Varithena
Solutions Center™ will need to use health information about you that it obtains from your health plan,
healthcare provider, and the pharmacy that will receive your doctor’s prescription (this information is called
“Protected Health Information” or “PHI”) to do so. This Authorization will allow your healthcare providers,
health plans, and health insurers that maintain PHI about you to disclose your PHI to the Varithena Solutions
Center™ so that the Varithena Solutions Center™ may provide these services to you or on your behalf.
By signing this Authorization, I authorize my physician, health plans, and pharmacy providers to disclose
information relating to my medical condition, treatment, care management, and health insurance, as
well as all information provided on this form and any prescription (“Protected Health Information”), to
the Varithena Solutions Center™ and its representatives, agents, and contractors (collectively, “Varithena
Solutions Center™”) for the following purposes: (1) to establish my eligibility for benefits; (2) to
communicate with my healthcare providers and me about my medical care; (3) to facilitate the provision
of products, supplies, or services to me by a third party including, but not limited to, specialty pharmacies
and copay assistance; (4) to register me in any applicable product registration program required for my
treatment; and (5) to communicate with my healthcare providers and me about the products. I understand
that my PHI disclosed under this Authorization may no longer be protected by federal privacy law and
may be re-disclosed by the Varithena Solutions Center™. I understand that I may refuse to sign this
Authorization and that my treatment, payment for treatment, enrollment, or eligibility for benefits is not
conditioned on my signing this Authorization. I understand that I am entitled to a copy of this Authorization
after I sign it. I understand that I may cancel this Authorization at any time by mailing a letter requesting
such cancellation to the Varithena Solutions Center™, PO Box 29215, Phoenix, AZ 85038, but that this
cancellation will not apply to any information already used or disclosed through this Authorization by my
healthcare providers and health plans before they learned of my cancellation. This Authorization expires
one (1) year from the date signed below.
I understand and agree that my physician, health plans, pharmacy providers, and other entities may
receive direct or indirect remuneration from Biocompatibles, Inc. in exchange for disclosing de-identified
data described herein to Biocompatibles, Inc. and/or for providing me with therapy support, information
regarding products, or other services subsidized by Biocompatibles, Inc.
Access and Reimbursement Services
Toll-Free Phone 1-855-971-VEIN (8346)
Toll-Free Fax 1-877-488-8599
Site of Service Information
If site of service is not the same as prescriber, please complete the section below
Member ID:
*Patient Signature:
*Patient Printed Name:
Patient’s Legal Representative:
Relationship to Patient:
Prescriber Information
*Treating Physician Name:
*Treating Physician Specialty:
Practice Name:
*Practice Address:
*City:
*State:
*Zip:
*NPI:
Medicare PTAN:
*Tax ID:
*DEA:
*Contact Person:
*Contact Phone #:
Contact Email:
*Fax #:
Access Preference:
BTG International Direct
Specialty Pharmacy Provider
Specialty Distributor
Clinical Information
Veins to be treated (check all that apply):
GSV
Accessory saphenous vein(s)
Visible varicosities
Characteristics of veins to be treated (check all that apply):
Large (>12 mm)
Tortuous
Recurrent
Above the knee
Below the knee
Treatments will be completed in the:
Right leg
Left leg
Bilateral
Previous treatments (check all that apply): None
Compression <3 mo
Compression ≥3 mo
Stripping/ligation
Thermal ablation (laser or RF)
Phlebectomy
Sclerotherapy
Disease severity: CEAP:
VCSS:
Symptom experience (check all that apply):
Heaviness
Swelling
Throbbing
Itching
Other:
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By signing below, I certify that I have obtained a valid consent from the patient listed on this form, authorizing
me to release the patient’s Protected Health Information to the Varithena Solutions Center™ as necessary to
obtain insurance coverage and payment for Varithena®.
*Physician Signature:
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Achiness
*Date:
Prescription Information
Varithena® (polidocanol injectable foam) 1%, for intravenous use
Sig: Administered by physician; inject as directed under ultrasound guidance.
*Dispense
units of bi-canister(s) (NDC 60635-118-01)
*Dispense
units of administration pack(s) (NDC 60635-123-01)
*Prescriber Signature Required (no stamps):
*Date:
*Denotes Mandatory Field
©2014 Biocompatibles, Inc., a BTG International group company. All rights reserved. 10/14
Varithena and Varithena Solutions Center are trademarks of Provensis Ltd., a BTG International group company. BTG and the BTG roundel logo are registered trademarks of BTG International Ltd.
US-VAR-2014-0021(2)