OSTEOPOROSIS REFERRAL FAX FORM Phone: (800) 299-9047 □ Patient □ Physician/Clinic Ship To: Date Shipment Needed: Rx: □ New □ Refill PATIENT INFORMATION Patient’s Full Name: Address: Patient SS#: City: State: Zip: Gender: Allergies: Home Phone: Alt. Phone: Patient's demographics, including insurance information (we will obtain authorization unless insurance dictates otherwise) □ INSURANCE INFORMATION Primary Insurance: ID#: □ 733.01 Senile Osteoporosis □ 733.03 Disuse Osteoporosis □ Other ICD 9: Date of Diagnosis: BMD/T-Score: If no, is patient at high risk? □ Yes □ No □ Yes □ No MEDICATION □ 733.02 Idiopathic Osteoporosis □ 733.09 Other Osteoporosis History of osteoporotic fracture? Prior (Failed) Therapy Therapy □ Yes □ No □ Yes □ No □ Yes □ No DOSE/STRENGTH Dates □ Fosamax □ Actonel □ Forteo □ Prolia □ Reclast □ Boniva □ Other: If yes, date of fracture: __________ Location of fracture:__________ Does patient have a pre-existing dental problem? Is patient undergoing any dental procedures? Phone: Please FAX recent clinical notes, labs and tests with the prescription to expedite the Prior Authorization □ 733.00 Osteoporosis, Unspecified □ 733.02 Idiopathic Osteoporosis □ 733.10 Pathologic Fracture Is patient new to therapy? □ History & Physical and/or Progress Note(s) confirming diagnosis Secondary Insurance: ID#: Phone: CLINICAL INFORMATION ICD-9: DOB: □ Male □ Female DIRECTIONS QTY □ BONIVA 3mg/3mL PFS Infuse 3mg IV every 3 months □ FORTEO 600mcg/2.4mL Pen Inject 20mcg SC once daily □ PROLIA 60mg/1mL PFS Inject 60 mg SC every 6 months □ RECLAST 5mg/100mL vial Infuse 5mg IV over no less than 15 min once annually □ XGEVA 120mg/1.7mL vial Inject 120mg SC once every 4 weeks □ ZOMETA 4mg/5mL vial REFILLS □ 4 week supply □ 12 week supply □ PEN NEEDLES □ OTHER Prescriber's Verification PRESCRIBER INFORMATION I have reviewed my patient’s medical record and determined the medication and/or supplies ordered on this form are medically necessary for the treatment of this patient. I verify I have physically examined the patient and established that the patient has a medical condition as diagnosed above. I agree to comply with state and federal documentation requirements by retaining a copy of this prescription in the recipient’s medical record. Prescriber's Name (Please Print): NPI#: Address: DEA#: City, State, Zip: Phone: REP: Fax: Contact Name: Prescriber's Signature: Date: I authorize ENTRACELL Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process. FA X O R D E R TO: 800- 667- 6079 IMPORTANT: Please include a faxed copy of the FRONT & BACK of the patient’s INSURANCE CARD