Specialty Injections
Order
Form
Crohn’s and Colitis
Therapy
Order
Form
Pittsburgh
305 Merchant Lane
Phone:
844-428-7387
PA 15205
"You'll
goodabout
aboutthePittsburgh,
the
choice"
"You'll feel
feel good
choice"
Fax: 844-228-7387
Phone:
844-428-7387
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Fax: 844-228-7387
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PATIENT
PATIENT INFORMATION
INFORMATION
Patient's
Patient's Name:
Name:
Prescriber's Name:
Prescriber's
Prescriber's Name:
Name:
Address:
Address:
Address:
City
City
City Contact:
Office
Office
Contact:
OfficeContact:
Contact:
Office
NPI:
NPI:
NPI:
State
State
State
Phone#
Phone#
Phone #
Phone#
DEA:
DEA:
DEA:
Fax#
Fax#
Fax #
Fax#
License:
License:
License:
SS#
SS #
Address:
Address:
State
State
Work
Work or
or Cell:
C ell:
Allergies:
Allergies:
N
N
Zip
Zip
Emergency
Emergency Contact:
C ontact:
Sex:
Sex: M____
M____ F____
F____ Wt:
Wt:
Patient
Patient previously
previously on
on treatment:
treatment: Y
Y
Primary
Insurance:
Primary Insurance:
Zip
Zip
Zip
DOB:
D O B:
City
City
Home
Home Phone:
Phone:
MD / DO / NP / PA
MD
MD // DO
D O // NP
NP // PA
PA
Ht:
Ht:
Diabetic:
Diabetic:
Y
Y
N
N
Date:
Date:
Insured:
Insured:
Policy#
Policy #
Group
Group
Phone:
Phone:
BIN#
BIN #
** Please
include
current
patient
Please include current patient medication
medication list
list with
with referral
referral *
*
PCN#
PCN #
TREATMENT
TREATMENT ARRANGEMENTS
ARRANGEMENTS
555.0 Crohn’s
555.1 Crohn’s Large Intestine
555.2
Crohn’s Small Intestine with Large Intestine
SHIP
Office
Primary
___________________________________________
Home ❏
❏ Home
❏ Doctors
SHIP MEDS:
MEDS: ❏
Doctors
Office Small Intestine
Primary Diagnosis:____________________
Diagnosis:____________________
___________________________________________
555.9 Crohn’s Unspecified Site
Anticipated Start
Start Date
Anticipated
Date _____________________
_____________________ Teaching
❏ Special
❏ Drs.
❏ Other
Teaching by:
by: ❏
Special
Design Healthcare
Healthcare ❏
Drs. Office
Office ❏
AureusDesign
Other
THERAPEUTIC FAILURE ON _____________________
_________________________________________________
_________________________________________________
Medication
Medication name:
name:
Strength
Strength // Dose
Dose
Directions
Directions for
for administration
administration
Aureus
Aureus
Refills
Refills x
x
®
RIFAXIMIN (Xifaxan®)
CETOLIZUMAB PEGOL (Cimzia )
Crohn’s and U.C. Starter Kit
Medication
Medication name:
name:
Prefilled Syringe starter kit for week 0, 2 and 4
(3 sets of 2PFS each containing 200mg)
400mg SQ every 4 weeks
Prefilled Syringes
Strength
Strength // Dose
Dose
Yes
No
30 Day Supply
550mg
Dose: Take 1 tab by mouth twice daily.
Swallow whole.
200mg tid X 3 days for (TD)
Refills x__________________________
Directions
Directions for
for administration
administration
GOLIMUMAB (Simponi )
50mg/0.5ml SmartJect PFS
50mg/0.5ml PFS
100mg/ml SmartJect PFS
100mg/ml PFS
Dose 200mg initially Sub Q at Week 0, followed
by 100mg at week 2 then 100mg every 4 weeks
Refills
Refills x
x
Refills x__________________________
BUDESONIDE (Uceris®)
Medication
Medication name:
name:
30 Day Supply
9mg extended release tablet taken
once daily for up to 8 weeks
Strength
Strength // Dose
Dose
Refills x__________________________
Directions
Directions for
for administration
administration
METHYLNALTREXONE (Relistor)
12mg/0.6ml vial
12mg/0.6ml PFS
8mg/0.4ml PFS
Use weight-based dosing guidelines in PI
to calculate individual daily dose.
Refills
Refills x
xTake_____mg every other day as needed
HYALURONIC ACID/
DEXTRONOMER (Solesta)
VEDOLIZUMAB (Entyvio)
300mg in 20ml vial - infuse over 30 minutes
at 0, 2, 6 weeks, then every 8 weeks
Refills x ______
50mg/ml gel syringe pack of 4 pouches
1 syringe/pouch with 5 sterile needles
Refills x__________________________
By signing this form and utilizing our services, you are authorizing Aureus and its employees to serve as your prior authorization designated agent in dealing with
medical and prescription insurance companies.
Prescriber
Prescriber Signature:
Signature:
May
May Substitute
Substitute
Dispense
Dispense as
as Written
Written
Date:
Date:
Form
# -# CRO-062014
Form
- CRO-052314