Multiple Sclerosis Enrollment 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:
Multiple Sclerosis
Enrollment
NPI:
Address:
Office:
Fax:
Main: 888-777-5547
Fax: 888-777-5645
1301 E. Arapaho Rd., Ste. 101
Contact:
Richardson, TX 75081
E-mail:
PATIENT INFORMATION
Name:
DOB:
SS#:
M
F
_____/_____/__________
_____-_____-__________
Tel:
Al. Tel:
Wt.:
Ht.:
English
Spanish
Other: ________
__________
__________
Street:
City:
State:
ZIP:
MEDICAL INFORMATION
Prior Failed Medication(s):
Length of Treatment
Reason for Discontinuing
_____/_____/_______-_____/_____/_______
_____/_____/_______-_____/_____/_______
Date of Diagnosis: ______/______/________
Is this patient nursing or planning pregnancy?
Allergies:
G35 Multiple Sclerosis
Yes
No
Number of relapses in the past year:
Other: _______________________________
______
Type:
Date of last MRI:
Relapse-remitting
Primary-progressive
____/____/______
Secondary-progressive
Progressive-relapsing
Were there any changes with the latest MRI?
Yes
No
***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
Pen
Avonex®
Inject 30mcg IM once weekly (Quantity: 4)
Pre-filled Syringe
Single-dose vial
INITIAL:
Weeks 1-2: Inject 0.0625mg/0.25ml SQ every other day (Quantity: 7)
Weeks 3-4: Inject 0.125mg/0.50ml SQ every other day (Quantity: 7)
Betaseron®
Vial
Weeks 5-6: Inject 0.1875mg/0.75ml SQ every other day (Quantity: 7)
Weeks 7+: Inject 0.25mg/1ml SQ every other day (Quantity: 7)
MAINTENANCE: Inject 0.25mg/1ml SQ every other day (Quantity: 14)
Copaxone®
Pre-filled Syringe
Inject 20mg SQ every day (Quantity: 30)
INITIAL:
Weeks 1-2: Inject 0.0625mg/0.25ml SQ every other day (Quantity: 7)
Weeks 3-4: Inject 0.125mg/0.50ml SQ every other day (Quantity: 8)
Extavia®
Vial
Weeks 5-6: Inject 0.1875mg/0.75ml SQ every other day (Quantity: 7)
Weeks 7+: Inject 0.25mg/1ml SQ every other day (Quantity: 8)
MAINTENANCE: Inject 0.25mg/1ml SQ every other day (Quantity: 15)
Gilenya™
Capsule
Take 0.5mg PO every day (Quantity: 28)
INITIAL: 44mcg titration protocol
Weeks 1-2: Inject 8.8mcg SQ three times a week (Quantity: 6)
Weeks 3-4: Inject 22mcg SQ three times a week (Quantity: 6)
Rebif®
MAINTENANCE: Inject 44mcg SQ three times a week (Quantity: 12)
Titration pack
INITIAL: 22mcg titration protocol
Pre-filled Syringe
Weeks 1-2: Inject 4.4mcg SQ three times a week (Quantity: 6)
Weeks 3-4: Inject 11mcg SQ three times a week (Quantity: 6)
MAINTENANCE: Inject 22mcg SQ three times a week (Quantity: 12)
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.
Multiple Sclerosis Enrollment
04 28 2016

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