Fillable Crohn'S/colitis Enrollment Form printable pdf download

Crohn’s / Colitis Enrollment Form

Patients must bring an original prescription to the pharmacy. Faxed prescriptions will only be accepted from a prescribing practitioner.

PATIENT INFORMATION

PRESCRIBER INFORMATION

)

(

Complete the following or include demographic sheet

Name:

State License #:

NPI #:

Patient Name:

DEA #:

Address:

City, State, Zip :

Group or Hospital:

Primary Phone:

DOB:

Address:

City, State Zip:

Alternate Phone:

Phone:

Fax:

Gender:

Male

Female

Primary Language:

Contact Person:

Phone:

INSURANCE INFORMATION

If available, please fax copy of prescription insurance cards with this form (front and back).

MEDICAL INFORMATION

Reason for Discontinuing

Prior Failed Medication(s):

Length of Treatment

_____/_____/_ _____ -_____/_____/_______

5-ASA

Corticosteroids

_____/_____/_ _____ -_____/_____/_______

Immunosuppressants (6-MP or other)

_____/_____/_ _____ -_____/_____/_______

Methotrexate

Other

Date of Diagnosis: ______/______/_ ______

TB/PPD Test Results:

Prior biologic use: Date of last dose:

Negative

K50.00 Regional enteritis of small intestine

Remicade®

______________

Positive

K50.10 Regional enteritis of large intestine

Humira®

_______________

Hepatitis B ruled out or being treated:

Regional enteritis of small intestine with large intestine

K50.80

Simponi®

______________

Yes

K50.90 Regional enteritis of unspecified site

Cimzia®

______________

K51.80 Ulcerative enterocolitis

K51.80 Ulcerative ileocolitis

K51.50 Left-sided ulcerative colitis

Allergies:

K51.00 Universal ulcerative colitis

K51.90 Ulcerative colitis, unspecified

Patient’s Weight:

Other: _ _________________________________________

PRESCRIPTION

Drug

Directions & Quantity

Refills

Cimzia

Prefilled Syringe

INITIAL: Inject 400mg SQ on day 1, 14, and 28 (Quantity: 6)

Lyophilized Powder

MAINTENANCE: Inject 400mg SQ every 4 weeks (Quantity: 2)

MAINTENANCE: Inject 200mg SQ every 2 weeks (Quantity: 2)

Humira

Crohn’s Starter Kit

INITIAL: Inject 160mg SQ on day 1, then 80mg on day 14 (Quantity: 6)

P en

MAINTENANCE: Inject 40mg SQ every other week (Quantity: 2)

P re-filled Syringe

Remicade

V ials

INITIAL: Infuse _ 5 mg /____kg=______mg on day 0, 14, and 42 (Quantity: _____)

MAINTENANCE: Infuse _ ____ mg every 8 weeks (Quantity: _____)

Simponi

S martJect® (Pen)

INITIAL: Inject 200mg SQ on day 1, then 100mg on day 14 (Quantity: 3)

P re-filled Syringe

MAINTENANCE: Inject 100mg SQ every 4 weeks (Quantity: 1)

INITIAL / MAINTENANCE : Week zero two and six

Entyvio

300mg in 20 mL V ial

weeks, then every eight weeks thereafter

INJECTION TRAINING

Patient has received pen and injection training

Physician’s office to provide injection training

Pharmacy t o coordinate injection training or infusion

PHYSICIAN SIGNATURE

To Physician: By signing this form and utilizing our services, you are also authorizing pharmacy to serve as your prior authorization agent in dealing with medical and prescription insurance companies,

and co-pay assistance foundations.

Physician

Signature:

Date:

_ ________________________

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under

applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as

to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee.

Crohn'S/colitis Enrollment Form

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