Fillable Enrollment Form printable pdf download

IBD

FAX:

1-855-322-2087

Enrollment

PHONE: 1-855-443-9944

Form

Deliver Medications To:

Doctor's Office

Date Needed By: ____________

Inj. Training/Admin.

Patient's Home

PATIENT DEMOGRAPHICS

Last Name:

First Name:

Date of Birth:

Street Address:

City:

State:

Zip:

Cell Phone:

Work Phone:

Home Phone:

PLEASE ATTACH A COPY OF THE FRONT AND BACK OF THE PATIENT'S CARD

Prescription Insurance:

Rx PCN: __________________

Primary Prescription Insurance: ___________________________________

Rx BIN: __________________

Patient Rx Group Number: ________________________________

Patient ID/Policy Number: ________________________________________

PATIENT CLINICAL INFORMATION/HISTORY: (PLEASE ATTACH A COPY OF PATIENT'S RECENT CHART NOTES, PATHOLOGY AND LABS)

Diagnosis: ___________________

ICD-10 Code: ___________________

Severity:

Moderate

Severe

Result: ___________________ Date: ___________________ Sex

Weight: _______ lbs or kg

TB Test

Yes

Does patient have active/serious infection?

Yes

Drug Allergies: ________________________________________________

Previous/Failed Medications:

Date and Duration of Therapy:

Reason for Discontinuation:

_________________________

PATIENT SUPPORT AND INJECTION TRAINING

I authorize Encompass Rx to enroll patient in the pharmaceutical company-assisted patient support program, corresponding with my prescribed therapy for purposes of receiving additional services such as, but not limited to, injection training. Patient further authorizes Encompass

to release and communicate to the corresponding manufacturer the minimum necessary information about their health condition and prescription(s) to: coordinate the delivery of products and services available through the patient assistance program, aggregate de-identified data

for market analysis, contact me occasionally for market research purposes, and provide educational information regarding therapies and disease states. I understand patient make revoke this authorization at anytime in writing by sending a letter to Encompass Rx: 1190 West Druid

Hills Dr. NE Atlanta, GA 30329. I understand that patient may refuse authorization and that refusal will not affect patient ability to obtain treatment from the pharmacy.

PRESCRIPTION INFORMATION

DRUG

STRENGTH

DIRECTIONS

QTY

REFILLS

Starter Kit

Induction Dose:

Inject 400mg sc on day 1, at week 2 and week 4, then maintenance dose

Cimzia

200mg PFS

Maintenance Dose:

Inject 400mg sc every 4 weeks

200mg Vial

Other: ____________________________________________________________________

Dificid

200mg Tablet

Take 1 tablet by mouth twice a day

Induction Dose:

300mg IV on weeks 0, 2 and 6

300mg Vial

Maintenance Dose:

300mg IV q 8 weeks

Entyvio

Other: ____________________________________________________________________

Inject 160mg sc on day 1, 80mg sc on day 15, then maintenance dose

IBD Starter Pack

Induction Dose:

Humira

40mg Pen

Inject 40mg sc every 2 weeks

40mg PFS

Other:__________________________________________________________________

Induction Dose:

IV at 5mg/kg (Each Dose = _____ mg) on weeks 0, 2 and 6

100mg Vial

Remicade

Maintenance Dose:

IV at 5mg/kg (Each Dose = _____ mg) q 8 weeks

Other:__________________________________________________________________

Induction Dose:

Inject 200mg sc on day 1, 100mg sc on day 15, then maintenance dose

100mg PFS

Simponi

Inject 100mg sc every 4 weeks

100mg AutoInjector

Other:__________________________________________________________________

Xifaxan

550mg Tablet

Take 1 tablet by mouth three times a day

PRESCRIBER INFORMATION

Prescriber Name:

Facility Group or Hospital:

City:

Zip:

State:

Street Address:

Office Fax:

Office Contact:

Office Phone:

UPIN:

NPI:

DEA:

Physician Signature: _____________________________

Date: _____________________________________

Enrollment Form

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