Senderra Specialty Pharmacy Patient & Medical Information Form

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Faxed 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:
Orthopedic
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
Forteo T-Score: __________ Site: __________ Date: __________
Enroll into Forteo Connect ongoing personalized support?
Fracture History Site: ____________________ Date: __________
Yes
No
Current Medications _____________________________________
Start Date of Therapy ______/______/_________
Referring PCP __________________________________________
(Forteo is not to exceed 2 years of therapy)
Prior Failed Medications
Initiation of Therapy
Continuation of Therapy
Actonel
Length of Treatment: ______/______/________-______/______/________ Reason for Discontinuing: ___________________
Boniva
Length of Treatment: ______/______/________-______/______/________ Reason for Discontinuing: ___________________
Fosamax
Length of Treatment: ______/______/________-______/______/________ Reason for Discontinuing: ___________________
Length of Treatment: ______/______/________-______/______/________ Reason for Discontinuing: ___________________
Prolia
Length of Treatment: ______/______/________-______/______/________ Reason for Discontinuing: ___________________
Reclast
Patient has not tried or failed any prior medication(s).
Diagnosis Date: ______/______/________
M80.0 Age Related Osteoporosis with Fracture
M85.9 Disorder of Bone Density and
M80.8 Other Osteoporosis with Fracture
Structure, Unspecified (Osteopenia)
Allergies:
M81.0 Age Related Osteoporosis without
M89.9 Disorders of Bone, Unspecified
Fracture (Senile/Postmenopausal)
M84.48XA to M84.40XA Pathological
M81.6 Localized Osteoporosis
Fracture, Unspecified Site
M81.8 Other Osteoporosis without Fracture
Other: _______________________
***PLEASE FAX COPY OF PRESCRIPTION/MEDICAL CARD FRONT AND BACK AS WELL AS ANY LAB NOTES REGARDING THERAPY***
PRESCRIPTION
New
Refill
Ship by:
____/____/_____
SHIP TO:
Patient’s Home
Doctor’s Office
Other: ___________________
Drug
Directions
Quantity
Refills
Inject 20 mcg SQ daily
600mcg/2.4mL
Forteo®
Pen
(1 pen)
30 days’ supply
Pen needles: Use with Forteo daily as directed
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.
Orthopedic Enrollment Form (Rev. 05/10/2016)

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