Fillable Growth Hormone Prescription/referral Form printable pdf download

Growth Hormone

2 Penns Way, Ste# 404

New Castle, DE 19720

Prescription/Referral Form

Tel: (877)246-9104

Please complete this form (Print) in it’s entirely. Be sure to include any necessary documentation, labs,

Fax: (302)544-5018

insurance cards, etc

Ship to:

Patient

Office

Other:

Date need by:_____________________________________

Patient Information

Prescriber Information

Prescriber’s Name:______________________________________________________________________

Patient Name:______________________________________________________

Address: _________________________________________________________

State License #: _____________________________ UPIN:____________________________________

City,State,Zip:_____________________________________________________

DEA:______________________________________ NPI:______________________________________

Home Phone:______________________________________________________

Practice Name:_________________________________________________________________________

Alternate Phone:___________________________________________________

Address:_______________________________________________________________________________

SSN#_______-________-_________ Primary Language:________________

City, State, Zip:_________________________________________________________________________

Date of Birth:________________________ Allergies:______________________

Phone:______________________________________ Fax:______________________________________

Gender:

Male

Female

Contact Person:______________________________ Phone:_____________________________________

INSURANCE INFORMATION

(Please copy and attach the front and back of insurance and prescription

card)

Prescription Card:

Name of Insurer:______________________________ ID#: _____________________ BIN:_________________PCN:_______________ Group:_________________

Primary Insurance:

Name of Insurer:______________________________ ID#: ______________________BIN:_________________PCN:_______________Group:_________________

Secondary Insurance: Name of Insurer:______________________________ ID#: ______________________ BIN:________________ PCN:_______________ Group:_________________

CLINICAL AND PRESCRIPTION INFORMATION

Diagnosis:

(Please chose from options

below)

Growth Hormone Deficiency in adults (Type of onset:

Adult onset

Child onset)

Chronic Renal Insufficiency

Growth Hormone Deficiency in Children

Prader Willi Syndrome (PWS

Small for Gestational Age: __________________Birth Weight: ______________________________ GA:

_______________________

Dwarfism – Noonan Syndrome

AIDS Wasting Syndrome

Short Bowel Syndrome

Turner Syndrome

Growth Failure in children with IGF-1 Deficiency

Idiopathic Short Stature

Dwarfism SHOX Deficiency

Other:_______________________________________________

Growth Failure in children with GH deletion & resistance GH

ADDITIONAL PATIENT INFORMATION:

Last Office Visit:______________________________________________ Bone Age:____________________ Chronological Age:___________________________ Date of

Test:___________________________

IGF-1: _______________________________________________________

Ref. Range:___________________________________ Date of Test:______________________________________

Growth Velocity (cm/year): ___________________________________ Height SD: _____________________________ Height:___________________________ _

Weight:_____________________________________

Provocative Testing Agent:____________________________________________ Response:_________________________________________ Date of

Test:_______________________________________________

Provocative Testing Agent:____________________________________________ Response:_________________________________________ Date of

Test:_______________________________________________

Please include any other pertinent history for the diagnosis, such as: clinical evaluation notes, lab tests (FSH, LH, TSH, ACTH), growth charts and list any other pertinent medication

history

Rx Information:

Drug Name and Strength: _____________________________________ Dose:______________ Sig:____________________________________________________________

Number of doses per week:____________________________________ Number of Refill(s):______________________ Days Supply:

90 day

30 day

Other:__________________________

Does the Patient need Injection training?

Yes

Patient needs Needles?

Yes

If Yes, Check to indicate Needle size:

32G

30G

Other: _________________________ QTY of Needles: ______________________________

By signing below, I authorize BioTek reMEDys to: Collect my health condition and prescription information from my doctor, healthcare provider, health insurer or pharmacist in order to

ensure its accuracy and completeness and to communicate to the patient support program of the pharmaceutical manufacturer (the program); and contact my insurer, other potential

funding sources, social workers, patient advocacy organizations, and patient assistance programs on my behalf to determine if I am eligible for assistance. I herby authorize my

doctor, healthcare provider, health insurer or pharmacist to provide my health condition and prescription information to BioTek reMEDys and to the program. I understand that I may

revoke this authorization at anytime by sending a letter to BioTek reMEDys at 2 Penns Way, Ste#404, New Castle, De, 19720.

Patient’s Signature: _________________________________________________________________________________________ Date: ______ _________________________

Prescriber Signature: ____________________________________________________________

_____________________________________________

Date: _____________________

(Substitution Allowed)

(Brand Medically

Necessary)

Fax completed form to: (302) 544-5018

Thank you for using BioTek reMEDys!

Important Information: 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 material. In no event should such material be read by anyone other than the named addressee, except by express authority of the sender to the named addressee.

Growth Hormone Prescription/referral Form

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