1. No category

Rheumatology 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)
714.0 Rheumatoid Arthritis
720.0 Ankylosing Spondylitis
Other: ____________________________________________________
Height:___________________ in/cm
696.0 Psoriatic Arthritis
714.3 Juvenile Idiopathic Arthritis
ICD-10 Code & Description: ______________________________________
Weight: ___________________ kg/lbs
Allergies:______________________________________________________
y PRESCRIPTION INFORMATION
MEDICATION
Actemra®
DOSE/STRENGTH
80 mg/4 mL
200 mg/10 mL
400 mg/20 mL
___mg/kg
DIRECTIONS
Patients less than 100 kg weight 162 mg administered subcutaneously every other week,
followed by an increase to every week based on clinical response
Patients at or above 100 kg weight 162 mg administered subcutaneously every week
Cimzia Starter Kit
Induction dose: inject 400mg subcutaneously on day 1, at week 2, and at week 4
200mg/1 mL Prefilled Syringe
200mg vial
Maint. Dose: Inject 200mg subcutaneously every OTHER week.
Maint. Dose: Inject 400mg subcutaneously every 4 weeks.
Other: _______________________________________________________________________
Enbrel®*
50mg/ml Sureclick™ Autoinjector
50mg/ml Prefilled Syringe
25mg/0.5ml Prefilled Syringe
25mg Vial
Inject 50mg subcutaneously ONCE a week.
Inject 25mg subcutaneously TWICE a week (72-96 hours apart).
Other:________________________________________________________________________
Humira®*
40mg/0.8ml Pen
40mg/0.8ml Prefilled Syringe
20mg/0.4ml Prefilled Syringe
Inject 40mg subcutaneously every OTHER week.
Inject 20mg subcutaneously every OTHER week.
Other:________________________________________________________________________
ILARIS®
4mg/kg (with a maximum of 300
mg) for patients with a body
weight greater than or equal to
7.5kg.
Administer subcutaneously every 4 weeks. ILARIS is supplied as a 180 mg white lyophilized
powder for solution for subcutaneous injection. Reconstitution with 1 mL of preservative-free
Sterile Water for injection is required prior to subcutaneous administration of the drug, resulting in
a total volume of 1.2 mL reconstituted solution.
Kineret®
100mg Prefilled Syringe
Otezla®
1 kit
(6 vials)
0
1
0
Inject 100mg (one syringe) SC once a day.
250mg Vial
Infuse ______mg in 100ml of 0.9% NaCl at weeks 0, 2, and 4, then every 4 weeks thereafter.
Other:________________________________________________________________________
125mg Orencia Subcutaneous
After single IV loading dose, inject 125mg subcutaneously within a day followed by 125mg
subcutaneous injections every week thereafter.
For patients unable to receive an IV loading dose, inject 125mg subcutaneously every week.
For patients transitioning from IV infusion therapy to subcutaneous therapy, inject 125mg
subcutaneously instead of the next scheduled IV dose followed by 125mg subcutaneous
injections every week thereafter.
Inject 125mg subcutaneously every week
Titration Starter Pack Rx
Take as Directed x14 days #27 tablets, 0 refills
Orencia®
REFILLS
Induction dose: 4 mg/kg every 4 weeks
Maint. Dose: (based on clinical response): 8mg/kg every 4 weeks
Other:________________________________________________________________________
162mg/0.9 mL Prefilled Syringe
Cimzia®
QUANTITY
Maintenance dose 30mg tablet orally twice daily
30 MG Tablet
Other:________________________________________________________________________
100mg Vial
Remicade®
_______ mg/kg
Induction Dose: IV in 250ml of 0.9% NaCl at weeks 0,2,and 6. (ICD-9: 714.0, 696.0, & 720.0)
Maint. Dose: IV in 250ml of 0.9% NaCl every 8 weeks. (ICD-9: 714.0 & 696.0)
Maint. Dose: IV in 250ml of 0.9% NaCl every 6 weeks. (ICD-9: 720.0)
Other:________________________________________________________________________
Page 1 of 2
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may contain
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confidential,
privileged,
proprietary
exempt from
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If anyone
it is
IMPORTANT
NOTICE: This
facsimile
is intended to
be delivered
only
to the named
and
may contain
that ismaterial
confidential,
proprietary
or exampt
from or
disclosure
underdisclosure
applicableunder
law. Ifapplicable
it is received
other than the named
addressee,received
the recipient
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immediately
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sender at the
and
telephone
number notify
set forth
and
instructions
as to disposal
of the
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material
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retained
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Rheumatology Enrollment Form
Fax Referral To:
Fax
Referral
To: 800-323-2445
Email
Referral
To:
Phone:
Email Referral To: [email protected]
Patient Information
Phone: 800-237-2767
Patient Name:________________________________ DOB:______________ Prescriber’s Name:______________________
MEDICATION
DOSE/STRENGTH
DIRECTIONS
QUANTITY
Rituxan®
100mg/10ml vial
500mg/50ml vial
Infuse two doses of 1000mg in 1 liter of 0.9% NaCl separated by 2 weeks.
Other:________________________________________________________________________
Simponi®
50mg/0.5ml Prefilled SmartJect
Autoinjector
50mg/0.5ml Prefilled Syringe
Inject 50mg (0.5ml) subcutaneously once a month
Other:________________________________________________________________________
Simponi®
ARIA™
50mg/4mL (12.5mg/ml) in a
single use vial
2 mg/kg intravenous infusion over 30 minutes at weeks 0 and 4, then every 8 weeks Dilution of
supplied SIMPONI ARIA solution with 0.9% w/v sodium chloride is required prior to
administration.
Stelara®
Injection 45 mg/0.5 mL in a
single-use prefilled syringe
Injection: 90 mg/mL in a singleuse prefilled syringe
The recommended dose is 45 mg SQ initially and 4 weeks later, followed by 45 mg SQ every 12
weeks. For patients with co-existent moderate-to-severe plaque psoriasis weighing>100kg (220
lbs), the recommended dose is 90 mg initially and 4 weeks later, followed by 90 mg every 12
weeks.
Xelijanz®
5mg
Take one 5mg tablet PO twice daily
Other:________________________________________________________________________
Patient is interested in patient support programs
STAMP SIGNATURE NOT ALLOWED
z x__________________________________
DISPENSE AS WRITTEN
REFILLS
60
120
180
Ancillary supplies and kits provided as needed for administration
x__________________________________
(Date)
PRODUCT SUBSTITUTION PERMITTED
(Date)
Page 2 of 2
IMPORTANT
NOTICE:
Thistransmission
facsimile transmission
to be
delivered
only toaddressee
the named
addressee
and material
may contain
that isprivileged,
confidential,
privileged,
proprietary
exempt from
applicable
law.by
If it
is
IMPORTANT
NOTICE: This
facsimile
is intended is
to intended
be delivered
only
to the named
and
may contain
that ismaterial
confidential,
proprietary
or exampt
fromor
disclosure
underdisclosure
applicableunder
law. If
it is received
anyone
other than the named
addressee,received
the recipient
shouldother
immediately
theaddressee,
sender at the
and
telephone
number notify
set forth
obtain
instructions
as to disposal
of the
In no
even should
material
or retained
by anyone
by anyone
than thenotify
named
theaddress
recipient
should
immediately
theherein
senderand
at the
address
and telephone
number
settransmitted
forth hereinmaterial.
and obtain
instructions
as such
to disposal
of be
theread
transmitted
material.
In noother
eventthan the named
addressee,should
exceptsuch
by express
authority
senderby
toanyone
the named
addressee.
RA 022614
material
be readoforthe
retained
other
than the named
addressee, except by express authority of the sender to the named addressee. Hepatitis C 022514