Multiple Sclerosis Reimbursement Support Form
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1MULTIPLE SCLEROSIS
REIMBURSEMENT SUPPORT FORM
PATIENT
PATIENT
PATIENT
PATIENT
Patient Name:_________________________________DOB:_______________SSN:________________________
Patient Name:_________________________________DOB:_______________SSN:________________________
Patient Name:_________________________________DOB:_______________SSN:________________________
Patient Name:_________________________________DOB:_______________SSN:________________________
Address: _____________________________________City:_____________________St:________Zip:_________
Address: _____________________________________City:_____________________St:________Zip:_________
Address: _____________________________________City:_____________________St:________Zip:_________
Address: _____________________________________City:_____________________St:________Zip:_________
Home Phone :(___) _______________Cell(____)________________Work Phone: (___) ____________________
Home Phone :(___) _______________Cell(____)________________Work Phone: (___) ____________________
Home Phone :(___) _______________Cell(____)________________Work Phone: (___) ____________________
Home Phone :(___) _______________Cell(____)________________Work Phone: (___) ____________________
*****ATTACH COPY OF PRESCRIPTION INSURANCE CARD*****
*****ATTACH COPY OF PRESCRIPTION INSURANCE CARD*****
*****ATTACH COPY OF PRESCRIPTION INSURANCE CARD*****
*****ATTACH COPY OF PRESCRIPTION INSURANCE CARD*****
PHYSICIAN
PHYSICIAN
PHYSICIAN
PHYSICIAN
MD Name:_____________________________________License:__________________DEA:__________________NPI:__________________
MD Name:_____________________________________License:__________________DEA:__________________NPI:__________________
MD Name:_____________________________________License:__________________DEA:__________________NPI:__________________
MD Name:_____________________________________License:__________________DEA:__________________NPI:__________________
Address:____________________________________________________________________________________________________________
Address:____________________________________________________________________________________________________________
Address:____________________________________________________________________________________________________________
Address:____________________________________________________________________________________________________________
Phone:(______)__________________________________Fax:(______)_________________________Contact:__________________________
Phone:(______)__________________________________Fax:(______)_________________________Contact:__________________________
Phone:(______)__________________________________Fax:(______)_________________________Contact:__________________________
Phone:(______)__________________________________Fax:(______)_________________________Contact:__________________________
CLINICAL INFORMATION
CLINICAL INFORMATION
CLINICAL INFORMATION
CLINICAL INFORMATION
Primary ICD-9:
Primary ICD-9:
Primary ICD-9:
Primary ICD-9:
Secondary ICD-9: Single demyelinating episode (high risk): __ Y
Secondary ICD-9: Single demyelinating episode (high risk): __ Y
Secondary ICD-9: Single demyelinating episode (high risk): __ Y
Secondary ICD-9: Single demyelinating episode (high risk): __ Y
__N
__N
__N
__N
Relapsing remitting disease:
Relapsing remitting disease:
Relapsing remitting disease:
Relapsing remitting disease:
__Y
__Y
__Y
__Y
__N
__N
__N
__N
Secondary progressive:
Secondary progressive:
Secondary progressive:
Secondary progressive:
__Y
__Y
__Y
__Y
__N
__N
__N
__N
Symptoms (check all that apply): __Tingling __Numbness __Pain __Limb weakness __ Double vision __Superimposed relapses
Symptoms (check all that apply): __Tingling __Numbness __Pain __Limb weakness __ Double vision __Superimposed relapses
Symptoms (check all that apply): __Tingling __Numbness __Pain __Limb weakness __ Double vision __Superimposed relapses
Symptoms (check all that apply): __Tingling __Numbness __Pain __Limb weakness __ Double vision __Superimposed relapses
__Balance disturbance
__Balance disturbance
__Balance disturbance
__Balance disturbance
__Other_________________________________
__Other_________________________________
__Other_________________________________
__Other_________________________________
Documented MS Attacks: __1-2 episodes
Documented MS Attacks: __1-2 episodes
Documented MS Attacks: __1-2 episodes
Documented MS Attacks: __1-2 episodes
__3-4 episodes __5-6 episodes __More than 7 __Unknown
__3-4 episodes __5-6 episodes __More than 7 __Unknown
__3-4 episodes __5-6 episodes __More than 7 __Unknown
__3-4 episodes __5-6 episodes __More than 7 __Unknown
MRI Evidence: Neurological inflammations in one area of CNS: __Y
MRI Evidence: Neurological inflammations in one area of CNS: __Y
MRI Evidence: Neurological inflammations in one area of CNS: __Y
MRI Evidence: Neurological inflammations in one area of CNS: __Y
Neurological inflammations more than one area of CNS: __Y
Neurological inflammations more than one area of CNS: __Y
Neurological inflammations more than one area of CNS: __Y
Neurological inflammations more than one area of CNS: __Y
Demyelinated lesions: __Y
Demyelinated lesions: __Y
Demyelinated lesions: __Y
Demyelinated lesions: __Y
PRESCRIPTION INFORMATION
PRESCRIPTION INFORMATION
PRESCRIPTION INFORMATION
PRESCRIPTION INFORMATION
DOSE/FREQUENCY/ROUTE
QUANTITY
REFILLS
MEDICATION
ACTHAR
AVONEX
BETASERON
COPAXONE
EXTAVIA
GILENYA
REBIF
OTHER:
By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to RX Biotech Specialty Pharmacy
Phone: (800) 657-2212 | Fax: (310) 657-0906
/Beverly Sinai Pharmacy to act as the prescriber’s agent to begin and execute the prior authorization process and to help the
patient apply to co-pay assistance programs, including all foundations and manufacturer assistance programs if necessary.
Physician’s Signature : ____________________________________________________ Date:______________
IMPORTANT NOTICE:
This message may contain privileged and confidential information and is intended only for the individual named. If you are not the named addressee, you should not
disseminate, distribute or copy this fax. Please notify the sender immediately if you have received this document by mistake then destroy this document.
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