Combined Dermatology 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)
696.1 Psoriasis
Other:
ICD-10 Code & Description:
Height:
y
696.0 Psoriatic Arthritis
In/cm
Weight:
172 Malignant Melanoma
kg/lbs
173 Basal Cell Carcinoma
Allergies:
PRESCRIPTION INFORMATION
MEDICATION
Enbrel®
Erivedge™
Humira®
DOSE/STRENGTH
50mg/ml Sureclick™ Autoinjector
50mg/ml Prefilled Syringe
25mg/0.5ml Prefilled Syringe
25mg Vial
150mg
DIRECTIONS
REFILLS
1
0
1
0
1 tablet by mouth once daily #30
Psoriasis Starter Package
Psoriasis Induction Dose: Inject two 40mg pens/syringes SC on day 1, then one 40mg pen/syringe
on day 8, then one 40mg pen every other week.
40mg/0.8ml Pen
40mg/0.8ml Prefilled Syringe
Psoriasis Maintenance Dose: Inject one 40mg pens/syringes SC every other week.
Psoriasis Arthritis Dose: Inject one 40 mg pen/syringe SC every other week.
Other:_________________________________________________________________________
Titration Starter Pack Rx
Take as directed x14 days #27 tablets, 0 refills
Otezla®
QUANTITY
Psoriasis Induction Dose: Inject 50mg SC TWICE a week (3-4 days apart) for 3 months, then
maintenance dosing.
Psoriasis Maintenance Dose: Inject 50mg SC ONCE a week.
Psoriatic Arthritis Dose: Inject 50mg SC ONCE a week.
Other:_________________________________________________________________________
Maintenance dose 30mg tablet orally twice daily
30 MG Tablet
Other:_________________________________________________________________________
Induction Dose: Infuse 5mg/kg in 250mL of 0.9% NaCl at week 0, week 2, week 6, and every 8
weeks thereafter.
Remicade®
100mg Vial
Maintenance Dose: Infuse 5mg/kg in 250ml of 0.9% NaCl every 8 weeks.
Other:_________________________________________________________________________
Simponi™
50mg/0.5ml SmartJect™
Autoinjector
50mg/0.5ml Prefilled Syringe
Stelara™
45mg/0.5ml prefilled syringe
90mg/mL prefilled syringe
Zelboraf®
240mg
Patient is interested in patient support programs
Psoriatic Arthritis Dose: Inject 50mg (0.5ml) subcutaneously once a month
Other:_________________________________________________________________________
For patients weighing < 100kg (220lbs): Inject 45mg SC initially and 4 weeks later, followed by
45mg every 12 weeks.
For patients weighing > 100kg (220lbs): Inject 90mg SC initially and 4 weeks later, followed by
90mg every 12 weeks.
4 tablets by mouth twice daily #240
STAMP SIGNATURE NOT ALLOWED
z x___________________________________
DISPENSE AS WRITTEN
(Date)
Ancillary supplies and kits provided as needed for administration
x___________________________________
PRODUCT SUBSTITUTION PERMITTED
(Date)
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