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Therapy Order Form
Pittsburgh
Lane
Phone:
844-428-7387
"You'll feel good about 305
theMerchant
choice"
Pittsburgh, PA 15205
Fax:
844-228-7387
'RFWRUV·3DUN‡&DSH*LUDUGHDX02
Phone: 844-428-7387
3KRQH‡)D[
Fax: 844-228-7387
)D[
Prescriber's
Prescriber's Name:
Name:
Address:
Address:
MD
MD // DO
D O // NP
NP // PA
PA
City
City
Office
Office Contact:
Contact:
State
State
Phone#
Phone #
DEA:
DEA:
NPI:
NPI:
PATIENT
PATIENT INFORMATION
INFORMATION
Patient's
Name:
Patient's Name:
Zip
Zip
Fax#
Fax #
License:
License:
SS#
SS #
Address:
Address:
DOB:
D O B:
City
City
Home
Home Phone:
Phone:
State
State
Work
Work or
or Cell:
C ell:
Allergies:
Allergies:
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:
N
N
Insured:
Insured:
Zip
Zip
Ht:
Ht:
Diabetic:
Diabetic:
Y
Y
N
N
Date:
Date:
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
SHIP
Primary Diagnosis:____________________
Home ❏
❏ Home
❏ Doctors
SHIP MEDS:
MEDS: ❏
Doctors Office
Office
Primary
Diagnosis:____________________ ___________________________________________
___________________________________________
Anticipated
Start
Date
_____________________
❏
❏
by: ❏ Special
Anticipated Start Date _____________________ Teaching
❏ Other
Teaching by:
Special
Design Healthcare
Healthcare ❏ Drs.
Drs. Office
Office ❏
AureusDesign
Other
Medication
Medication name:
name:
Strength
Strength // Dose
Dose
Directions
Directions for
for administration
administration
Aureus
Aureus
Refills
Refills x
x
Medication
Medication name:
name:
Strength
Strength // Dose
Dose
Directions
Directions for
for administration
administration
Refills
Refills x
x
Medication
Medication name:
name:
Strength
Strength // Dose
Dose
Directions
Directions for
for administration
administration
APREMILAST (Otezla®)
30 day supply
❑ 30mg TITR Starter Pak - (2 Week Supply)
❑ 30mg po BID - (30 Day Supply)
Refills
Refills x
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
Therapy Order Form
Pittsburgh
Lane
Phone:
844-428-7387
"You'll feel good about 305
theMerchant
choice"
Pittsburgh, PA 15205
Fax:
844-228-7387
'RFWRUV·3DUN‡&DSH*LUDUGHDX02
Phone: 844-428-7387
3KRQH‡)D[
Fax: 844-228-7387
)D[
Prescriber's
Prescriber's Name:
Name:
Address:
Address:
MD
MD // DO
D O // NP
NP // PA
PA
City
City
Office
Office Contact:
Contact:
State
State
Phone#
Phone #
DEA:
DEA:
NPI:
NPI:
PATIENT
PATIENT INFORMATION
INFORMATION
Patient's
Name:
Patient's Name:
Zip
Zip
Fax#
Fax #
License:
License:
SS#
SS #
Address:
Address:
DOB:
D O B:
City
City
Home
Home Phone:
Phone:
State
State
Work
Work or
or Cell:
C ell:
Allergies:
Allergies:
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:
N
N
Zip
Zip
Ht:
Ht:
Diabetic:
Diabetic:
Y
Y
N
N
Date:
Date:
Policy#
Policy #
Insured:
Insured:
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
SHIP
Primary Diagnosis:____________________
Home ❏
❏ Home
❏ Doctors
SHIP MEDS:
MEDS: ❏
Doctors Office
Office
Primary
Diagnosis:____________________ ___________________________________________
___________________________________________
Anticipated
Start
Date
_____________________
❏
❏
by: ❏ Special
Anticipated Start Date _____________________ Teaching
❏ Other
Teaching by:
Special
Design Healthcare
Healthcare ❏ Drs.
Drs. Office
Office ❏
AureusDesign
Other
Medication
Medication name:
name:
Strength
Strength // Dose
Dose
Directions
Directions for
for administration
administration
Aureus
Aureus
Refills
Refills x
x
BELIMUMAB (Benlysta ®)
28 Day Supply
RInfuse 10mg/kg
diluted in 250ml
of NS over one hour at week 0, 2, 4 and then every 4 weeks
Medication
name:
Medication
name:
RNS Syringe 10ml IV before and after infusion and as needed. #Qs
Refills x_______
Strength
Strength // Dose
Dose
®
TOCILIZUMAB
(Actemra
)
Directions for
administration
Directions
for administration
80mg/4ml
vials
200mg/10ml
vials
400mg/20ml vials
R 50ml 0.9% NS bag
R 100ml 0.9% NS bag
Sig: __________________________(Above vials will be used to fill dose)
28 days
Refill x ____
R NS 0.9% 10ml PFS to flush line before and after infuson
Refills x
x
Qty: qs Refills
Refills x ____
R 162mg/0.9mL PFS
Medication
name:
Medication
name:
R Dosage:
Patients<100kg
(220lbs) 162mg (sc) every other week followed
by an increase to every week based on clinical response
R Dosage:
Patients>100kg
(220lbs) 162mg (sc) every week
Strength
// Dose
Strength
Dose
Refills x ____
Directions
Directions for
for administration
administration
TOFACITINIB (Xeljanz)
Dose: 5mg tab by mouth twice daily.
Qty: 60
x
Refills
x
Refill xRefills
__________
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