Fillable Pcsk9 Inhibitor Enrollment Form printable pdf download

PCSK9 INHIBITOR ENROLLMENT

PHONE: 888-903-7453 FAX: 800-530-8589

Patient:__________________________________________________________Caregiver: __________________________________________

SS#:_________________________________ DOB:______________________________

Male or

Female

Address:_________________________________________________ City:______________________ State:__________ Zip:______________

Best Phone #:_________________________________

Cell

Alternate Phone #:_________________________________

Cell

Weight:________

kgs or

lbs (check one)

Recorded Date:_________________

Allergies:_____________________________ ________

PLEASE FAX COPY OF ALL INSURANCE CARDS (FRONT & BACK) INCLUDING MEDICAL AND PRESCRIPTION

Diagnosis/ICD-10:

Previous/Current Therapies:

Hypercholesterolemia (MUST select at least one)

___ none

____ mg/day

______ date

LDL-C ______

______ date

__ E78.0 Pure hypercholesterolemia

For ASCVD patients, MUST

___ atorvastatin

____ mg/day

______ date

LDL-C ______

______ date

__ E78.2 Mixed hyperlipidemia

select appropriate code for

hypercholesterolemia AND ASCVD

__ E78.4 Other hyperlipidemia

____ mg/day

______ date

LDL-C ______

______ date

___ ezetimibe

Clinical ASCVD (check all that apply)

___ ezetimibe/

____ mg/day

______ date

LDL-C ______

______ date

Ischemic Heart Disease

simvastatin

__ I21.3 ST elevation (STEMI) myocardial infarction of unspeciﬁed site

___ fenofibate

____ mg/day

______ date

LDL-C ______

______ date

__ I24.8 Other forms of acute ischemic heart disease

____ mg/day

______ date

LDL-C ______

______ date

___ niacin

__ I25.89 Other forms of chronic ischemic heart disease

__ I25.2 Old myocardial infarction

___ pravastatin

____ mg/day

______ date

LDL-C ______

______ date

__ I20.9 Angina pectoris, unspeciﬁed

___ rosuvastatin

____ mg/day

______ date

LDL-C ______

______ date

__ I25.89 Other forms of chronic ischemic heart disease

___ simvastatin

____ mg/day

______ date

LDL-C ______

______ date

Cerebrovascular and Peripheral Vascular Disease

__ I65.8 Occlusion and stenosis of other pre-cerebral arteries

___ Intolerance to statins (list medications and dose failed): _____________________________

__ I66.8 Occlusion and stenosis of other cerebral arteries

___ Rhabdomyolysis

___ Myositis

___ Myalgia

__ G45.9 Transient cerebral ischemic attack, unspeciﬁed

___ Baseline LFT’s: _________________________________________________________

__ I69.998 Other sequelae following unspeciﬁ ed cerebrovascular disease

__ I70.90 Unspeciﬁed atherosclerosis

Other ASCVD-specific code(s) _________________________

______ 10 year ASCVD Risk %

MEDICATION

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

___

Repatha

___ 140 mg/mL Prefilled Syringe

___ Inject 140 mg Sub-Q every 2 weeks

___ 1 pack = 1 x 140 mg/mL Prefilled Syringe

___

___ 140 mg/mL SureClick

___ Inject 420 mg Sub-Q every 4 weeks

___ 1 pack = 1 x 140 mg/mL SureClick

___

___ 2 pack = 2 x 140 mg/mL SureClick

___

___ 3 pack = 3 x 140 mg/mL

Praluent

___ 75 mg/mL Pen

___ Inject 75 mg Sub-Q every 2 weeks

1 Carton = 2 x 75 mg/mL

___

___ 75 mg/mL Prefilled Syringe

___ 150 mg/mL Pen

___ Inject 150 mg Sub-Q every 2 weeks

1 Carton = 2 x 150 mg/mL

___

___ 150 mg/mL Prefilled Syringe

INJECTION TRAINING:

OFFICE TO COORDINATE

PRAXISRx TO COORDINATE

Anticipated Start Date: ___________________________ Prescriber Specialty: ____________________________________________ _________

Ship to:

Patient

Physician

Clinic

Other:_____________________________________________________________ ___________

Prescriber: ______________________________________________ NPI #: ________________________ Phone #: ______________________

Fax #: ______________________________Contact Name: ____________________________________________________________________

Office Address: ___________________________________________________________ City: __________________ State: _____ Zip: _______

I authorize PraxisRx and its representatives to act as an agent to initiate/execute the insurance prior authorization process, coordinate and receive patient lab values,

and coordinate injection training.

Physician’s Signature: _________________________________________________________________ Date: ___________________________

Confidentiality Statement: This message is intended only for the individual or entity to which it is addressed. It may contain information which may be proprietary and confidential. It may also contain privileged, confidential information which is exempt from

disclosure under applicable laws, including the Health Insurance Portability and Accountability Act (HIPAA). If you are not the intended recipient, please note that you are strictly prohibited from disseminating or distributing this information (other than to the

intended recipient) or copying this information. If you received this communication in error, please notify the sender immediately by calling (888) 903-7453 to obtain instructions as to the proper destruction of the transmitted material.

Pcsk9 Inhibitor Enrollment Form

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