Inflammatory Bowel Disease Enrollment Form

Inflammatory Bowel Disease

6040 Tarbell Road

Enrollment Form

Syracuse, NY 13206

Phone: 888-843-2040

Fax: 888-842-3977

Please fax the completed form to

Signature Care Program

888-842-3977

Delivery Need By:

Delivery to:

Patients Home

Physician’s Office

Other

PATIENT INFORMATION

PRESCRIBER INFORMATION

Patient Name

Female

Prescriber Name

Male

Address

Address

City, State, Zip

City, State, Zip

,

,

,

,

Phone

Phone

Date of Birth

Fax

Social Security Number

DEA/NPI#

INSURANCE – PLEASE FAX COPY OF PRESCRIPTION CARD FRONT & BACK

CLINICAL INFORMATION

Diagnosis/ICD-10 Code:

K50.00

K50.019

K50.118

K50.80

Has the patient been treated previously for this condition?

K50.018

K50.10

K50.119

K50.818

Other

Yes

No

Height

Weight

Medications failed

feet

inches

lbs.

Allergies

Medications on

Last PPD Test

D/M/Y

Other Notes

Positive

Negative

Date:

/ /

PRESCRIPTION INFORMATION

Medication

Dosage/Strength

Directions

Quantity

Refills

Cimzia®

Starter Kit

Initial Dose Inject 400mg SC at weeks 0,2, and 4, then:

4 week supply

200 mg/ml Prefilled SYR

Maintenance Dose:

200mg SC every other week OR

400mg SC every 4 weeks

Entyvio®

300mg Vial

Loading Dose: Infuse 300mg SC at weeks 0,2, and 6

Loading Dose

Maintenance Dose: Infuse 300mg SC every 8 weeks

8 week supply

Other:

Other:

40mg/0.8ml Pen

Inject 40mg SC every OTHER week

4 week supply

Humira®

40mg/0.8ml Prefilled SYR

Inject 40mg SC ONCE a week

Other:

40mg/0.8ml Pen x6 (Starter Kit)

Inject 160mg (4 pens) SC Day 1 and 80mg (2 pens) on Day 15

Initial 4 week supply

Humira®

Crohn’s Starter

Inject 80 mg (2 pens) Day 1 and 80mg (2 pens) Day 2 then

Kit/UC/HS

80mg (2 pens) on Day 15

Remicade®

100mg Vial

IV

mg at 0, 2, and 6 weeks (induction)

# of vials

IV

mg every 8 weeks (maintenance)

IV

mg every

weeks

100mg/1ml SmartJect AutoInjector

Inject 100mg SC ONCE a month

4 week supply

Simponi®

100mg/1ml Prefilled SYR

Other:

90mg/ml Prefilled SYR *(Maintenance

Inject 90mg SC 8 weeks after infusion then continue every 8

16 week supply

Stelara®

Crohn’s

dosing only)

weeks

Other:

Other:

Ancillary supplies provided for administration

Patient is interested in patient support programs

Physician Signature: __________________________ Date: ____________

E-Scribe Rx and Fax this Form to 888-842-3977

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