Osteoporosis Referral Form
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1OSTEOPOROSIS
REFERRAL FORM
Phone: 800-657-2212
Fax: 310-657-0906
Preferred Language: __________
Please FAX TO:
Date Shipment needed
310-657-0906
____________
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 :(___) ____-______Cell(___)____-______
Address:________________________________________
Work Phone: (___) ____-______
City:_________________State:_______ZIP:___________
Language Spoken: ______________________________
Physician’s Ph: (____)____________-________________
Patient Soc. Sec #:________________________
Physician’s Fax: (____)____________-_______________
_______
Date of Birth:_________________________________
Nurse/Key Office Contact:_________________________
Specialty: ________________e-mail:_________________
See attached demographic sheet
INSURANCE INFORMATION
( Attach Copies of Cards and fax along this form)
CLINICAL INFORMATION
Diagnosis: ______________________ ICD-9 Codes:_____________
Allergies: ______________________
Home Health Nurse Required:
No
Yes
Please list failed meds relevant to the diagnosis:
Please indicate all relevant lab results:
(bisphosphonates, calcium+D, anabolic agents, etc)
Med
dose
duration
reason to D/C
____________ _____________ __________ _________________
____________ _____________ __________ _________________
lowest Dexa Score: _________ Site: _______________
____________ _____________ __________ _________________
Fracture: yes
no
Site: ________________
____________ _____________ __________ _________________
Other Clinical Findings: __________________________
____________ _____________ __________ _________________
______________________________________________
____________ _____________ __________ _________________
______________________________________________
TREATMENT
DOSE
DIRECTION
REFILLS
Boniva
3mg/3ml inj
3mg ivp q 3 months
____
Forteo
600mcg/ 2.4 ml, 12wks supply x 2yrs 20 mcg sq qd, needle 31G/5mm # 100 PRN
____
Prolia
60mg/ml ___prefilled syr
60mg sq q 6 months
____
Reclast
5 mg/100 ml #1
IV once per year
____
Other (specify): ____________________________________________________________________________
Comments:
________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
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: _________________
: _____________________________________________________________
Patient Signature: ______________________________________________________________________________
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.
RX BIOTECH – OSTEOPOROSIS REFERRAL FORM
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