Gilotrif PRESCRIPTION & ENROLLMENT FORM

Gilotrif
PRESCRIPTION & ENROLLMENT FORM
1 PATIENT INFORMATION
❑ New patient ❑ Current
Patient’s name ________________________________________________________________________________________
Date of birth ________________________ ❑ Male ❑ Female
Last 4 digits of SSN ___________________________
Street address __________________________________________________________________________ Apt # ________
City _____________________________________________________________________ State _______ Zip ___________
Parent/guardian (if applicable) ___________________________________________________________________________
Home phone ______________________ Work phone ______________________ Cell phone _______________________
Evening phone ______________________ E-mail address ____________________________________________________
Insurance company ________________________________________________________ Phone ______________________
Insured’s name ________________________________________________________________________________________
Insured’s employer _________________________________________________ Relationship to patient ______________
Identification # ______________________________________ Policy/group # ____________________________________
Prescription card: ❑ Yes ❑ No If yes, carrier _______________________________________________________________
Policy # _______________________ Group # ______________________ Is patient eligible for Medicare? ❑ Yes ❑ No
Patient’s primary language: ❑ English ❑ Other If other, please specify _____________________________________________
Please attach front and back copy of patient’s insurance cards, if available.
2 PRESCRIBER INFORMATION
4 PRESCRIBING INFORMATION
All fields must be completed to
expedite prescription fulfillment.
Date _________ Time _________
Prescriber’s name and title _____________________________________________________________________________
Office contact ________________________________ Clinic/hospital affiliation _________________________________
Street address _________________________________________________________________________ Suite # _______
City _____________________________________________________________________ State _______ Zip ___________
Phone _____________________________________________ Fax _____________________________________________
NPI # _____________________________________________ License # _________________________________________
MD specialty _________________________________________________________________________________________
Medication
Strength / Formulation
Directions
Quantity
Gilotrif (afatinib)
❑ 20 mg tablet
❑ 30 mg tablet
❑ 40 mg tablet
❑ Take _______ mg tablet daily.
Dispense:
❑ 30-day supply
❑ Other _____________________
❑ Other __________
Refills _________
If shipped to physician’s office, physician accepts on behalf of patient for administration in office.
By signing below, I certify that the above therapy is medically necessary.
I authorize HUB to act on my behalf for the limited purposes of transmitting this prescription to the appropriate pharmacy
designated by the patient utilizing their benefit plan.
Prescriber’s printed name ________________________________________________________________ Date ____________________
(Physician attests this is his/her legal signature. NO STAMPS)
Prescriber’s signature (sign below)
____________________________________________
Dispense as written
____________________________________________
Substitution allowed
This prescription is valid only if transmitted by means of a facsimile machine.
New York Prescribers please submit prescription on an original NY State prescription blank.
3 CLINICAL INFORMATION
Diagnosis: ❑ 162.3 ❑ 162.4 ❑ 162.5 ❑ 162.8 ❑ 162.9 ❑ Other ___________
The patient has tested positive for EGFR mutation: ❑ Yes ❑ No
Current weight _________ kg/lbs Date wt obtained ___________
❑ NKDA ❑ Known drug allergies _______________________________________________________________________
____________________________________________________________________________________________________
Concurrent meds _____________________________________________________________________________________
____________________________________________________________________________________________________
The document(s) accompanying this transmission may contain confidential health information that is legally privileged. This information is
intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this
information to any other party unless required to do so by law or regulation. If you are not the intended recipient, you are hereby notified that
any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly prohibited. If you have received
this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
All rights in the product names, trade names, or logos of all third-party products that appear in this form, whether or not appearing with
the trademark symbol, belong exclusively to their respective owners.
© 2014 Accredo Health Group, Inc. | An Express Scripts Company | All Rights Reserved
ONC-00053-092514 amc5670
❑ 90-day supply
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To reach your team, call toll-free 844.569.2836.
Please fax completed form to 888.454.8488.