Allergic Asthma 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): 493. 493. Asthma Asthma ICD-10 Code & Description: Patient Evaluation: Height: Allergies: y in/cm Weight: kg/lbs PRESCRIPTION INFORMATION MEDICATION DOSE/STRENGTH DIRECTIONS Every 4 weeks dosing: Xolair® (Omalizumab) 150mg vial kit Administer 150mg per dose subcutaneously every 4 weeks Administer 300mg per dose subcutaneously every 4 weeks Other: Administer __________________ mg per does subcutaneously every 4 weeks Please supply one vial of sterile water (10ml per vial) for every vial of Xolair® dispensed and include ancillary supplies (syringe and needle, alcohol swabs). Every 2 weeks dosing: Administer 225mg per dose subcutaneously every 2 weeks Administer 300mg per dose subcutaneously every 2 weeks Administer 375mg per dose subcutaneously every 2 weeks Other: Administer __________________ mg per dose subcutaneously every 2 weeks Supplies: • 1 vial sterile water for injection (10 mL vial) for ever vial of Xolair® dispensed • Alcohol swabs • Flexible bandages 1” x 3” • 3 mL Luer Lock injection syringe • NDL 18G x 1 & ½” Safety Glide needle for reconstitution • NDL 25G x 5/8” Safety Glide needle for subcutaneous injection Send quantity sufficient for medication days supply. QUANTITY REFILLS 30-day supply* 12 months 90-day supply* ____ ____ month supply* *Maximum supply subject to health benefit limit No supplies (The above supplies will be sent with shipment unless indicated.) EpiPen® Use as directed. 1 EpiPen® Jr. Use as directed. 1 I certify that the rationale for Xolair® therapy for Allergic Asthma is necessary for this patient and I will be supervising the patient’s treatment accordingly. Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED z x___________________________________ DISPENSE AS WRITTEN (Date) Ancillary supplies and kits provided as needed for administration x___________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Hepatitis C 022514