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 THIS AREA INTENTIONALLY LEFT BLANK. To reach your team, call toll-free 844.569.2836. Please fax completed form to 888.454.8488.