Form L10111-1113 - General Enrollment Form
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1General Enrollment Form
2601 West Beltline Hwy, Ste 302, Madison, WI 53713 / Phone: (855) 847-3553 / Fax: (855) 847-3558
Ship to:
Patient
Offi ce
Other
Date:
Needs by Date:
PATIENT INFORMATION
PRESCRIBER INFORMATION
Patient Name
Prescriber Name
Specialty
Address
State License #
UPIN
Address 2
DEA
NPI
City, State, ZIP
Group/Hospital
Preferred Phone
Type
Address
Alternate Phone
Type
City, State, ZIP
Email
Phone
Fax
Offi ce Contact
Phone
DOB (mm/dd/yyyy)
Gender
Male
Female
INSURANCE INFORMATION
(Please fax FRONT and BACK copy of all Insurance cards (Prescription and Medical)
CLINICAL INFORMATION
Diagnosis (Please include diagnosis name and ICD-10)
Therapy:
New
Reauthorization
Restart
Primary Diagnosis: _______________________________________________
Lab Data: ______________________________________________________
ICD-10: ________________________________________________________
Has the patient been previously treated for this condition?
Yes
No
Date of Diagnosis: _______________________________________________
Prior failed medication (medication and duration of treatment/reason for d/c):
Weight: __________________ lbs/kgs Height :___________________in/cm
______________________________________________________________
Is the patient pregnant, nursing, or planning pregnancy?:
Yes
No
N/A
Who to administer injection (if applicable): _____________________________
Allergies: ______________________________________________________
Patient trained on injection? (if applicable):
Yes
No
Concomitant medications: _________________________________________
Pharmacy injection training needed? (if applicable):
Yes
No
______________________________________________________________
Additional comments: _____________________________________________
PRESCRIPTION INFORMATION
Medication
Dose/Strength
Directions
Qty
Refi lls
By signing below, I authorize Lumicera Health Services and its representatives to act as my agent for prior authorization and prescription processing for this patient.
Prescriber Signature: ______________________________________________________________________
_________________
______________________________
PRODUCT SUBSTITUTION PERMITTED
Date
DISPENSE AS WRITTEN
L1011-1113
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Parent category: Business