Rheum Referral Form
Transcription
Rheum Referral Form
Oncology Enrollment Form Houston Location Fax to: (888) 478-4541 4126 Southwest Frwy Ste 100 Houston, TX. 77027 PATIENT INFO • Date: Name: CLINICAL INFO. Mobile Phone: PLEASE FAX COPY OF INSURANCE CARD (FRONT & BACK) Diagnosis □ □ □ ) ) ) (diag. code: (diag. code: (diag. code: ● Date of diagnosis: ____________ Drug Dosage form/strength Afinitor® Gleevec® Sprycel® Tasigna® Tarceva® Temodar® tem ozolom ide Xeloda □ Patient □ □ Male Office □ Female City, State, Zip: Oncology/ Chem otherapy Agents PRESCRIPTION INFORMATION • Ship To: DOB: Address: Home Telephone: INSURANCE INFO: ® capecitabine Lupron Depot® □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ 2.5mg tablet 5mg tablet □ □ □ □ □ 500mg tablet □ □ 7.5mg tablet 10mg tablet 100mg tablet 400mg tablet 25mg □ 70mg □ 100mg 50mg □ 80mg □ 140mg 150mg capsule 200mg capsule 100mg tablet 150mg tablet 5mg capsule □ 250mg capsule 20mg capsule 100mg capsule 140mg capsule 180mg capsule 150mg tablet 7.5mg: q1-mth administration 22.5mg: q3-mth administration 30mg: q4-mth administration 45mg: q6-mth administration Supportive Care: Anti-em etics • Tablets: □ 4mg; □ 8mg; □ 24mg Zofran® ondansetron • Other: Supportive Care: Hem atopoietics Aranesp ® Procrit® Neulasta® Neupogen® □ □ □ □ □ □ □ □ □ □ 25mcg □ 100mcg □ 300mcg 40mcg □ 150mcg □ 500mcg 60mcg □ 200mcg □ pref. syr. □ vial autoinjector 10,000u/ml □ 20,000u/ml (MDV) 40,000u/ml □ 20,000u/2ml (MDV Other: 6mg prefilled syringe 300mcg □ 480mcg prefilled syringe □ vial ● ● ● ● Weight: kg or Hgb/HCT: ⁄ BSA: m2 Other meds: Directions Office Address: NPI#: ● Height: ● WBC: ● ANC: □ □ Refills 30 100mg: _______ 400mg: _______ □ 30 □ Other: ____ □ 120 □ Other: ____ □ 30 □ Other: ____ _____mg: ______ _____mg: ______ Other: □ 150mg tabs: ____________ □ 500mg tabs: ____________ □ 1 syringe kit □ Other: _____ □ □ □ Autoinj: _____ Pref. syr: ______ vials: ______ □ □ Take 1 tablet by mouth ____ time(s) a day □ □ Inject contents of one (1) autoinj./syringe SC ONCE a week Inject contents of one (1) autoinj./syringe SC ONCE EVERY □ □ □ Other: Inject contents of one (1) vial SC ONCE a week Other: __________________________________________________ ______ vials □ □ □ □ Inject one (1) prefilled syringe SC ONCE per chemo cycle Other: Inject contents of one (1) syr./vial SC ONCE a day x __ days Other: □ inches Quantity Take one (1) tablet by mouth ONCE a day Other: Take ____ tablets by mouth ONCE a day Take ____ 400mg tabs & ____ 100mg tabs po ONCE a day Other: Take one (1) tablet by mouth ONCE a day Other: Take 2 tablets po TWICE a day on an empty stomach with water Other: Take one (1) tablet by mouth ONCE a day on an empty stom. Other: Initial: Take ___ capsules of _____mg and ___ capsules of ____mg by mouth once a day for ____ days (then maint. dosing) □ Maintenance: Take ___ capsules of _____mg and ___ capsules of ____mg by mouth once a day for 5 days per 28-day tx cycle □ Other: 2,500mg/m2 in two divided doses Dosing □ □ 2,000mg/m2 in two divided doses Take _______mg po BID on days 1-14 of a 21-day cycle Directions □ □ Other: □ Inject contents of one (1) syringe IM every 4 weeks □ Inject contents of one (1) syringe IM every 12 weeks □ Inject contents of one (1) syringe IM every 16 weeks □ Inject contents of one (1) syringe IM every 24 weeks Other: OTHER week Use as directed Injection Training Physician's office to provide injection training City: DEA#: PRODUCT SUBSTITUTION PERMITTED lbs □ □ □ □ □ □ □ □ □ □ □ □ ReCept HEMATOLOGY CARE PAK (com plim entary) □ Patient has received pen and injection training Practitioner's Name: Telephone: SS#: General info/labwork SHARPS CONTAINER, PRN vial syringes (1cc/27g/1/2") & ETOH pads PRESCRIBER INFORMATION Phone: (800)-650-0107 • Date Needed: (DATE) Contact person: Fax: ______ pref. syr. ______ vials 1-mth supply □ prn ReCept to coordinate injection training State: Medicaid Provider #: DISPENSE AS WRITTEN ______ pref. syr. Zip: I authorize ReCept Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process. (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. REF.012.R31.3.15