Acthar Enrollment Form
Download a blank fillable Acthar Enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Acthar Enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Faxed prescriptions will only be accepted from a prescribing practitioner. Patients must bring an original prescription to the pharmacy, and cannot fax these referral forms to Senderra.
Prescribing Practitioner:
NPI:
Acthar
Enrollment
Supervising Physician:
NPI:
Address:
Office:
Fax:
Main Tel: 888-777-5547
1301 E. Arapaho Rd., Ste. 101
Contact:
Fax: 888-777-5645
Richardson, TX 75081
PATIENT INFORMATION
Name:
DOB:
SS#:
M
F
_____/_____/__________
_____-_____-__________
Tel:
Al. Tel:
Wt.:
Ht.:
English
Spanish
Other: ________
________
________
Street:
City:
State:
ZIP:
MEDICAL INFORMATION
Tried & Failed (Duration):
Not Tolerated:
Previously Failed:
Contraindication:
History of Corticosteroid Use
__________________
(___________________)
_________________________
A corticosteroid was tried with the
following response(s):
__________________
(___________________)
_________________________
__________________
(___________________)
_________________________
Patient hypersensitive or allergic
Patient intolerant to corticosteroids
Date of Diagnosis: ___/____/______
Corticosteroid use failed, but same response
M06.9 Rheumatoid Arthritis
M32 System Lupus Erythematosus (SLE)
not expected with Acthar
M33.90 Dermatomyositis
M33.2 Polymyositis
Other:______________________________
L40.5 Psoriatic Arthritis
M45.9 Ankylosing Spondylitis
______________________________________
D86.9 Sarcoidosis
M08.0 Juvenile Rheumatoid Arthritis
G35 Multiple Sclerosis
OR
Is Acthar to be used to treat an acute exacerbation?
Yes
No
(If Yes, date of onset: __/___/_____)
G40.822 Infantile spasm, without intractable epilepsy
A corticosteroid was not tried due to the
Has diagnosis been confirmed by EEG?
Yes
No
following response(s):
G40.821 Infantile spasm, with intractable epilepsy
Corticosteroid use is contraindicated for this
Has diagnosis been confirmed by EEG?
Yes
No
patient
R80.9 Proteinuria
Patient has known intolerance to
corticosteroids
Please indicate etiology:
Focal segmental glomerular sclerosis
IgA nephropathy
Intravenous access is not possible for this
Lupus nephritis
Membranous nephropathy
patient
H16.9 Keratitis, Unspecified
H20.0 Iridocyclitis, Unspecified acute and subacute
Other:______________________________
H44.139 Sympathetic Uveitis, Unspecified
H30.009 Chorioretinitis and focal Retinochoroiditis
H46.9 Optic Neuritis, Unspecified
H16.4 Corneal Neovascularization, Unspecified
______________________________________
Other: ________________________
Allergies:
***PLEASE FAX COPY OF PRESCRIPTION/MEDICAL CARD, FRONT AND BACK, AS WELL AS ANY CLINICAL NOTES REGARDING THERAPY***
PRESCRIPTION
New
Refill
Ship by:
____/____/_____
SHIP TO:
Patient’s Home
Doctor’s Office
Other: ___________________
Drug
Directions & Quantity
Refills
Schedule/Frequency:
Dose: __________
Route of Administration:
Quantity:
______________________
Acthar®
5mL multidose vial
Units
mL
IM
SQ
______________________
Sharps Container
1cc syringe
Quantity:
Supplies
Syringe
23 G x 1"
Quantity:
Needles
25 G x 5/8"
Quantity:
INJECTION TRAINING
Patient has received pen and injection training
Physician’s office to provide injection training
Senderra Rx to coordinate injection training
PRESCRIBING PRACTITIONER SIGNATURE
To Prescribing Practitioner: By signing this form and utilizing our services, you are also authorizing Senderra Rx to serve as your prior authorization designated
agent in dealing with medical and prescription insurance companies, and co-pay assistance foundations.
Prescribing Practitioner:
Date:
____/______/________
____
CONFIDENTIALITY NOTICE
IMPORTANT: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, proprietary or exempt from disclosure under applicable law. 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 in error and then
destroy this document immediately.
Acthar Enrollment Form (Rev. 06/01/2016)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical