Makena Specialty Order Form Prescriber's Name: MD / DO / NP / PA Address: City Phone: 844-428-7387 Fax: 844-228-7387 State Office Contact: Office Contact: Phone# Phone# NPI: PATIENT INFORMATION Send updates to Fax Fax# Fax# DEA: Tax ID: E-mail to _________________________ Patient's Name: Zip Text to Phone# _________________ DOB: SS# Address: City Home Phone: State Work or Cell: Allergies: Emergency Contact: Sex: M____ F____ Wt: Patient previously on treatment: Y N Date: Primary Insurance: Zip Diabetic: Ht: African American Caucasian Native American Other Y N Asian Latin/Hispanic Pacific Islander Insured: Please send copy of Insurance Card * Please include current patient medication list with referral * DIAGNOSIS INFORMATION Primary ICD-9:________________________________________________________________________________________________ Secondary ICD-9:___________________________________________ Other ICD-9 Code:__________________________________ CLINICAL INFORMAATION – Please complete in entirety. CURREN PREGNANCY: Current Gestational Age: _____ weeks _____ days Date Recorded: _______________ Yes No Is the patient pregnant with a singleton? Yes Yes No Is the patient experiencing preterm labor? No Does the patient have a cerclage? Where will the Medication be administered? Office Home Anticipated Start Date Gravida: Para: 0 0 1 1 2 2 3 3 Other: _______ Other: _______ Gestational Age of prior preterm birth: ______ weeks Yes No Has the patient had a previous spontaneous singleton preterm birth (earlier than 37 weeks gestation)? Yes No Has the patient had any previous preterm birth? If yes, please check indication(s) that apply: If Home, please list CPT code requested ________ TREATMENT ARRANGEMENTS OB HISTORY: Multiple gestation Fetal complications Home Doctors Office Ship Meds: Aureus Teaching by: Drs. Office Maternal complications Incompetent cervix Lab in Box: Y or N Other Rx: Makena® (hydroxyprogesterone caproate injection) 250mg / mL multidose vial Dispense 1 vial, followed by ____ refills for a complete course of therapy Sig: Inject 1mL IM each week By By signing signingthis this form form and and utilizing utilizing our our services, services,you youare areauthorizing authorizingAureus SDHC and and its employees employeesto toserve serveas asyour yourprior priorauthorization authorization designated designated agent agentin in dealing dealingwith with medical and prescription insurance insurance companies. Prescriber Signature: May Substitute Dispense as Written Date: Form Form # - Makena-090514 # - HEP-041514