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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®
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□
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2.5mg tablet
5mg tablet
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□
□
□
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500mg tablet
□
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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®
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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: _____
□
□
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Autoinj: _____
Pref. syr: ______
vials: ______
□
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Take 1 tablet by mouth ____ time(s) a day
□
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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
□
□
□
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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
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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