Oncology Referral Form

RX BIOTECH

SPECIALTY PHARMACY

ONCOLOGY

Phone: 800-657-2212

REFERRAL FORM

Fax: 310-657-0906

Please FAX TO: 310-657-0906

Date Shipment needed____________

Toll Free Ph: 800-657-2212

Ship To:

Patient

Physician

PATIENT

PHYSICIAN

Patient Name:__________________________________

Physician Name:_________________________________

Address: _____________________________________

State Lic. #:______________DEA#__________________

City:_________________ State:______ Zip:_________

NPI: ___________________Tax ID#_________________

Home Phone :(___) ____________________________

Address:________________________________________

Work Phone: (___) ____________________________

City:_________________State:_______ZIP:___________

Cell Phone: (___) ______________________________

Physician’s Ph: (____)____________-________________

Patient Soc. Sec #:_______________ Language :_______

Physician’s Fax: (____)____________-_______________

Date of Birth:_________________________________

Nurse/Key Office Contact:_________________________

***PLEASE ATTACH COPIES OF FRONT AND BACK OF

Specialty:______________________________________

INSURANCE CARDS-PRESCRIPTION AND MEDICAL***

Prior Chemotherapy Drug

Reason for Discontinuation of Therapy

Year of Discontinuation

__Finished Therapy

__Disease Progression

_____________________

__Toxicity_____________________________

__Other_______________________________

CLINICAL INFORMATION

Diagnosis: ______________________ ICD-9 Codes:_____________

Allergies: ______________________

Patient: Weight:_________ Height:__________ BSA:________ Serum Creatinine:____________________________________________

Renal Dysfunction: __yes __no

Liver Dysfunction: __yes __no

H/H (Hemoglobin/Hematocrit) ________/_________

***TO EXPODITE PRIOR AUTHORIZATION SERVICES, PLEASE PROVIDE CHEMO REGIMEN SCHEDULE, LAST

CLINICAL NOTES AND/OR LAB VALUES/SCANS ETC…***

PRESCRIPTIONS

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TARCEVA: Strength________________________ Sig:________________________ Refill: ______

Cisplatin

Carboplatin

Patient experienced disease progression despite treatment with another antineoplastic agent ___Yes or __No

Patient has a diagnosis of pancreatic cancer and Tarceva will be used in combination with Gemzar __Yes or __No

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AFINITOR Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

CEENU

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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GLEEVEC

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

o

HYCAMTIN Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

o

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INLTYA

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

KYTRIL

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

o

NEXAVAR Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

o

PROMACTA Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

o

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SPRYCEL

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

SUTENT

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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SYLATRON Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

o

__Induction dose: 6mcg/kg/week for 8 doses.

__Maintenance dose: 3mcg/kg/week for 5 years

TASIGNA

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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TARGRETIN Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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TEMODAR

Strength: ____________________ Total dose of:______________ mg po daily for _______days

Refill:_________

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THALOMID Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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Thalomid Authorization #:______________________________________

TYKERB

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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VOTRIENT

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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XELODA

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

__Take for 14 days followed by 7 days of rest for ___________cycles

__ Take on Mon-Fri only for _________ weeks

__Take for 7 days followed by 7 days of rest _________cycles

__Other __________________________________

ZOLINZA

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

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ZOFRAN

Strength: ____________________ Sig:_______________________________ Qty:_____________ Refill:_________

ZYTIGA

Directions: ____mg administered orally ________ daily Sig:____________________ Qty: _________ Refill:_________

o

ICD-9 Code: 185

Diagnosis: Metastatic prostate cancer, Castration-resistant, in patients who received prior chemotherapy containing docetaxel.

Prednisone: ______mg administered orally twice dailly Sig:__________________________ Qty:_______ Refill:_______

OTHER______________________ Strength: _________ Sig:_______________________________ Qty:_______ Refill:________

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By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to RX Biotech Specialty Pharmacy /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.