Oral Chemotherapy Agents Prescription/referral Form

Tel: (800) 906-7798 / Fax: (877) 381-3806

ORAL CHEMOTHERAPY AGENTS

Prescription/Referral Form

Please complete this form (PRINT) in its entirety. Be sure to

 

enclose any necessary documentation, labs, insurance cards, etc.

PATIENT DEMOGRAPHICS:

PRESCRIBER INFORMATION:

WEIGHT: _______  lbs  kg   HEIGHT________ 

SPECIALTY: ________________________

SEX: M F

PRESCRIBER’S NAME: _____________________________________________________

PATIENT NAME: ______________________________________________

CLINIC NAME: ___________________________________________________________

A

DDRESS: ________________________________________________________________

ADDRESS: _________________________________ SUITE #: ____________

ADDRESS 2: ______________________________________________________________

CITY: ____________________________________ STATE: ______ ZIP: _____________

CITY: _______________________________________ STATE: ______ ZIP: __________

LICENSE #: _______________________________ DEA#: ________________________

HOME PHONE: ________________________ WORK PHONE: ______________________

NPI#: ___________________________ EMAIL: ________________________________

CELL PHONE: ________________________ EMAIL: ______________________________

CONTACT NAME & TITLE: __________________________________________________

DATE OF BIRTH (mm/dd/yyyy): _______________ SOCIAL SECURITY #: ____________

PHONE: ________________________________ FAX: ___________________________

ALLERGIES: ______________________________________________________________

INSURANCE INFORMATION:

Please include copies of medical & prescription cards (front/back).

PRIMARY INSURANCE: _______________________________________ POLICY HOLDER: ____________________________________________ POLICY #: _____________________

GROUP #: __________________________________ EMPLOYER: _______________________________________ INSURANCE PHONE #: ___________________________________

SECONDARY INSURANCE: ____________________________________ POLICY HOLDER: ____________________________________________ POLICY #: _____________________

GROUP #: __________________________________ EMPLOYER: _______________________________________ INSURANCE PHONE #: ___________________________________

CLINICAL INFORMATION:

(Please choose from options below)

DIAGNOSIS:

ICD-9: _________________

Multiple Myeloma (MM)

 Small Cell Lung Cancer – SCLC

Please describe extent of the disease (local,

advanced, metastatic, stage of disease, etc.)

Non-Small Cell Lung Cancer (NSCLC )

 Glioblastoma Multiforme –GBM

___________________

Advanced Renal Cell Carcinoma

 Primary Cutaneous T-cell Lymphoma

___________________

Transfusion-dependent Anemia due to

low/intermediate-1-risk Myelodysplastic Syndrome (MDS)

___________________

with 5q cytogenic abnormality

 Gastrointestinal Stromal Tumors - GIST

Philadelphia Chromosome-positive Acute

___________________

Lymphoblastic Leukemia

 Pancreatic Cancer

___________________

Philadelphia Chromosome-positive Chronic

 Prevention of recurrence of (GIST) after tumor

Myelogenous Leukemia (CML)

removal

___________________

Advanced Unresectable Hepatocellular Carcinoma

 Chronic Lymphocytic Leukemia (CLL)



___________________

B-cell Chronic Lymphocytic Leukemia

 Refractory Anaplastic Astrocytoma



 

 Breast Cancer

OTHER:

Is this a continuation of therapy?  YES  NO

Please attach any additional medical information that may aid in processing this prescription request.

 Afinitor®

 Arimidex®  Aromasin®

 Emend®

 Gleevec®

 Hycamtin®  Nexavar®

 Oforta®

 Revlimid®*  Sprycel®

 Sutent®

 Tarceva®  Targretin®

 Tasigna®

 Temodar®

 Thalomid®

 Tykerb® 

 Votrient®  Xeloda® 

 Zolinza®   Other: 

*If Revlimid request, please attach the completed Revlimid Patient Prescription form.

Strength:______________________ SIG (Directions):____________________________________________________ Refill(s):________

Quantity:  90 day  30 day  other: _______

By signing below, I authorize Acro Pharmaceutical Services (“Acro”) to collect my health condition and prescription information from my doctor, healthcare provider, health insurer or

pharmacist in order to ensure its accuracy and completeness and to communicate to the patient support program of the pharmaceutical manufacturer (the “Program”); and contact my insurer, other

potential funding sources, social workers, patient advocacy organizations, and patient assistance programs on my behalf to determine if I am eligible for assistance. I hereby authorize my doctor,

healthcare provider, health insurer or pharmacist to provide my health condition and prescription information to Acro and to the Program. I understand that I may revoke this authorization at

anytime by sending a letter to Acro at 313 Henderson Drive, Sharon Hill, PA 19079. Patient’s Signature: ________________________________

DELIVER MEDICATION TO:

 PATIENT’S HOME

 PHYSICIAN’S OFFICE

 OTHER: ______________________________

REQUESTED DATE OF DELIVERY: ______________________________________

PRESCRIBER’S SIGNATURE: ___________________________________________

DATE: ________________________

SUBSTITUTION ALLOWED

Fax completed form to: (877) 381-3806 /

Thank you for using Acro Pharmaceutical Services!

Important Notice:

This communication contains information that is confidential and protected from disclosure. If the reader of this message is not the intended recipient, employee or agent responsible for

delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in

 

error, please reply to the sender that you have received the message in error and destroy this copy.

ACRO.OCHEMO.1010