Hyaluronic Acid Enrollment Form
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1Phone: 866-788-7710
Hyaluronic Acid
Fax: 888-292-1228
Enrollment Form
PATIENT INFORMATION
Patient Name
Male
Female
Allergies
NKDA
Date of Birth
SSN#
Weight ________
kg
lb Date
Address
City
State
Zip
Phone # (Home)
(Work)
Email address(optional)
INSURANCE INFORMATION
Primary Insurance
Policyholder
Group #
Policy #
Phone #
Secondary Insurance
Policy#
Phone #
DIAGNOSIS / MEDICAL INFORMATION
(PLEASE ANSWER ALL QUESTIONS TO PREVENT A DELAY IN PATIENT’S THERAPY.)
Diagnosis and ICD-10 Code:
PRESCRIPTION INFORMATION
Medication
Dose
Directions
Quantity
Refills
The agents below may be obtained through BioScrip:
Inject 20 mg intra-articularly in the knee
3 syringes
Euflexxa
(Sodium Hyaluronate)
20 mg/2 ml
once weekly
6 syringes (bilateral only)
left
right
bilateral
__________ syringes
Inject 16 mg intra-articularly in the knee
1 kit
16 mg/2 ml
once weekly
2 kits (bilateral only)
Synvisc
(Hylan G-F 20)
(3 syringes/kit)
left
right
bilateral
_____________________
Inject 48 mg intra-articularly once in the
1 syringe
48mg/6 ml
knee
Synvisc-One
(Hylan G-F 20)
2 syringes (bilateral only)
left
right
bilateral
The agents below must be obtained through BioScrip per UCH 2013 Provider Administrative protocol
(For commercial members, available at: > Home > Tools & Resources > Policies, Protocols and Guides)
Hyalgan
(Sodium Hyaluronate)
3 syringes
Inject 20 mg intra-articularly in the knee
5 syringes
Clinical rationale for use of Hyalgan
20 mg/2 ml
once weekly
________________________________
6 syringes (bilateral only)
left
right
bilateral
10 syringes (bilateral only)
________________________________
_______________________
®
3 syringes
Orthovisc
(Hyaluronan)
Inject 30 mg intra-articularly in the knee
4 syringes
®
Clinical rationale for use of Orthovisc
30 mg/2 ml
once weekly
6 syringes (bilateral only)
________________________________
left
right
bilateral
8 syringes (bilateral only)
________________________________
_______________________
3 syringes
Supartz
(Sodium Hyaluronate)
Inject 25 mg intra-articularly in the knee
5 syringes
Clinical rationale for use of Supartz
25 mg/2.5 ml
once weekly
6 syringes (bilateral only)
________________________________
(5 syringes/kit)
left
right
bilateral
10 syringes (bilateral only)
________________________________
_______________________
Gel-One
(Cross-linked Hyaluronate)
Inject 30 mg intra-articularly once in the
1 syringe
Clinical rationale for use of Gel-One
30 mg/3 ml
knee
2 syringes (bilateral only)
________________________________
left
right
bilateral
__________ syringes
Other:
DELIVERY INSTRUCTIONS
Other:
Prescriber’s Office
Date Medication
Address
Needed
Patient’s Home
City/State/Zip
PHYSICIAN CONTACT INFORMATION & AUTHORIZATION
Physician Name
Office Contact
Institution
Phone
Fax
Specialty
Address
City/State/Zip
License #
DEA #
NPI #
Physician’s Signature ___________________________________________________________________________ Date _______________________
(required to process prescription – stamped signatures are not permissible)
BioScrip 09/30/2015
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Parent category: Medical