Xeomin Botulinium Toxin - Statement Of Medical Necessity Form

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XEOMIN® (incobotulinumtoxinA) - BOTULINIUM TOXIN
STATEMENT OF MEDICAL NECESSITY
Please complete this form (PRINT) in its entirety and fax it to the number below.
Tel: (800) 906-7798 Fax: (877) 381-3806
Be sure to enclose any necessary documentation, labs, insurance cards, etc.
PATIENT DEMOGRAPHICS
PRESCRIBER INFORMATION
SEX: M F
PATIENT NAME: ______________________________________________
PRESCRIBER’S NAME: _____________________________________________________
ALLERGIES:________________________________ Weight: ______lbs/kg Height:______
MD LICENSE #: ______________________ MD NPI#: ___________________________
DATE OF BIRTH: _______________ SOCIAL SECURITY #: ________________________
CLINIC NAME: _______________________________SPECIALTY:___________________
A
CONTACT NAME: ________________________________________________________
DDRESS: _________________________________________________ APT#_________
ADDRESS: _________________________________ SUITE #: ____________________
CITY: ______________________________________ STATE: ______ ZIP: __________
CITY: _________________________________ STATE: ________ ZIP: ____________
HOME PHONE: ________________________ WORK PHONE: ______________________
PHONE: _____________________________ FAX: ______________________________
CELL PHONE: ________________________ EMAIL: ______________________________
INSURANCE INFORMATION
Please include copies of the patient’s insurance/drug benefit cards (front and back) .
INSURANCE INFORMATION
PRIMARY INSURANCE: _______________________________________ RELATIONSHIP:
SELF
SPOUSE
CHILD
POLICY #: __________________________________
OTHER INSURANCE: _________________________________________ POLICY #: _____________________________ INSURANCE PHONE #: _______________________________
CLINICAL INFORMATION
1) PHYSICIAN’S SPECIALTY (REQUIRED, SPECIFY ALL SPECIALTIES): _____________________________________________________
CLINICAL INFORMATION
2) DIAGNOSIS FOR DRUG REQUESTED (MUST INCLUDE ICD-9 – Check X accordingly or fill information next to OTHER):
Please include copies of the patient’s insurance/drug benefit cards (front and back) .
333.60 FOCAL/SEGMENTAL LIMB DYSTONIAS
333.81 BLEPHAROSPASM
333.83 CERVICAL DYSTONIA
PRIMARY INSURANCE: _______________________________________ RELATIONSHIP:
SELF
SPOUSE
CHILD
POLICY #: __________________________________
343.00 INFANTILE CEREBRAL PALSY
351.80 HEMIFACIAL SPASM
378.00 STRABISMUS
OTHER INSURANCE: _________________________________________ POLICY #: _____________________________ INSURANCE PHONE #: _______________________________
728.85 SPASM OF THE MUSCLE (SECONDARY DIAGNOSIS REQUIRED)
OTHER (SPECIFY ICD-9) _______________
3) PATIENT MEDICAL INFORMATION: (Please Circle YES or NO accordingly)
FOR HYPERHIDROSIS:
a) Is the age of onset of hyperhidrosis 25 years or less?
YES
NO
b) Is focal sweating bilateral and relatively symmetric?
YES
NO
c) Does the patient sweat during sleep?
YES
NO
d) Does the patient have a positive family history of severe primary focal hyperhidrosis?
YES
NO
e) Does the hyperhidrosis significantly impair the patient’s participation in daily activities? YES
NO
f) Does the patient have any underlying disease? If yes please specify...
YES
NO
FOR MIGRAINE OR PROBABLE MIGRAINE:
a) Is the frequency of migraine >15 days per month?
YES
NO
b) Does the headache last >4 hours per day? YES
NO
4) PATIENT HISTORY (PLEASE LIST ANY PREVIOUS OR CURRENT THERAPIES RELATED TO THE DIAGNOSIS):
DRUG NAME
DATES
DURATION
___________________________________
_________________________
_______________________________
___________________________________
_________________________
_______________________________
___________________________________
_________________________
_______________________________
PLEASE ADD ANY OTHER SUPPORTING MEDICAL INFORMATION THAT MAY BE USEFUL IN THE DECISION-MAKING PROCESS:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PRESCRIPTION INFORMATION
Select Medication with an “X”. Indicate quantity of vials and complete directions below in the respective sections.
DRUG NAME AND QUANTITY
Xeomin 100 unit vial: Quantity _____
Xeomin 50 unit vial: Quantity_____
DIRECTIONS / DOSING
Day Supply
Refills
Sig:________________________________________________________________________________________
____________
________
______________________________________
_____________________________________
Prescriber’s Signature
Date:
Substitution Allowed
Deliver Medication to:
Patient’s Home
Physician’s Office
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 t he 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
Prescriber’s Signature ______________________________________ Date: ______________________________________
Patient’s Signature:
_______________
understand that I may revoke this authorization at anytime by sending a letter to Acro at 313 Henderson Drive, Sharon Hill, PA 19079.
Substitution Allowed
Deliver Medication to:
Patient’s Home
Physician’s Office
Other: _________________________________
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.
AcroMktXeomin113103
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

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