Fillable Oncology Form - Tnh Specialty Pharmacy printable pdf download

Fax: 855 356 1096

ONCOLOGY

Toll Free: 877 849 9591

REFERRAL FORM

Rx:

Ship to:  Patient  Physician/Clinic Date Shipment Needed:

 New  Refill ________

________________

PATIENT INFORMATION

Diagnosis:

ICD10 Code:

Patient’s Full Name:

Patient Weight:

Height:

Address:

Primary Insurance:

City, State, Zip:

ID#:

Phone:

Home Phone:

Secondary Insurance:

Alt. Phone:

Patient SS#:

DOB:

ID#:

Phone:

Allergies:

Gender:  Male

 Female

PLEASE FAX COPY OF INSURANCE CARD (FRONT & BACK)

PRESCRIPTION INFORMATION

 Pomalyst

 Revlimid

 Thalomid

 Female Child - NOT of Reproductive Potential  Adult Female - NOT of Reproductive Potential

 Female Child - Reproductive Potential

 Adult Female - Reproductive Potential

Dose: ___________ Qty: ________ Directions: ______________________

 Male Child

 Adult Male

Authorization: ______________________ Date: ____________________ Confirmation #: ______________________ Date: ____________________

(Pharmacy Use Only)

 Dexamethasone

Dose: _______________________ Qty: ________________ Directions: _______________________________________________

 Zytiga

250mg 4 QD (on empty stomach) Qty: ______________ Refill: __________________



I.V.I.G

 WITH Prednisone

5 mg BID w/ food

Qty: ______________ Refill: __________________

 Femara

 Ninlaro

 Tarceva

 Zolinza

DOSE/QUANTITY/DIRECTION:

 Afinitor

 Alecensa

 Gleevec

 Noxafil

 Tasigna

 Zydelig

 Hycamtin

 Odomzo

 Temodar

 Zykadia

 Arimidex

 Ibrance

 Sprycel

 Tykerb

 Aromasin

 Bosulif

 Jadenu

 Sutent

 Votrient

 Jakafi

 Stivarga

 Xeloda

 Cotellic

 Mekinist

 Tafinlar

 Xtandi

 Erivedge

 Farydak

 Nexavar

 Tamoxifen

 Zelboraf

Refill #: __________________________

INJECTABLES

IV INFUSION

SUPPORT DRUGS

DOSE/QUANTITY/DIRECTION:

 Emend

 Herceptin

 Aranesp

 Lovenox

 Pegasys

 Avastin

 Heparin Flush

 Lupron

 Perjeta

 Arixtra

 Reclast

 Erbitux

 NS Flush

 Folotyn

 Neulasta

 Procrit

 Promacta

 Gazyva

 Rituxan

 Fragmin

 Neupogen

 Sandostatin

 Sancuso

 Kadcyla

 Leukine

 Nplate

 Sylatron

 Zofran

Refill #: _______________

PRESCRIBER INFORMATION

# of Prescriptions:

___________

Physician’s Name

NPI#:

(Please Print)

Address:

License#:

City, State, Zip:

DEA#:

Phone:

Fax:

Contact Name:

Physician’s Signature:

Date:

I authorize TNH Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process.

IMPORTANT NOTICE: This message is intended for use of only the named addressee and may contain information that is proprietary and confidential. 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.

- The prescription form is valid only if faxed directly by the prescriber or his/her authorized representative. Original prescription drug orders can only be accepted directly from patients.

- The prescriber attests that he/she has advised the patient with the option of choosing a pharmacy of his/her choice.