Rheumatology Prescription And Enrollment Form Orchard Specialty printable pdf download

Rheumatology Enrollment Form

☐New to Therapy

☐Current Therapy

Fax: 877-309-0687 Call: 877-437-9012

Patient Information

Clinical Information and Prescription

Diagnosis and Clinical Information:

Patient Name: _________________________________________________

☐M06.9 Rheumatoid Arthritis ☐M45.9 Ankylosing Spondylitis ☐L40.59 Psoriatic Arthritis

☐M08.01 Juvenile chronic polyarthritis ☐Other:___________________________________________________________

Date of Birth: ________________________ Gender

Male or Female

Date of Diagnosis or Years with Disease: ____________________Patients Allergies: ______________________________

Address: _____________________________________________________

Latex allergy: ☐ Yes ☐ No

RAPID-3 Score:______________

MHAQ Score: ______________

City: ___________________State:_____________Zip: ________________

Patient Weight: ___________________kg / lbs

Patient Height: _____________________cm / in

Home Phone: ___________________ Work Phone: ___________________

Has the patient had a NEGATIVE tuberculin skin test? ☐ Yes ☐ No

Cell Phone: ________________ E-mail: ____________________________

Is the patient a carrier of the Hepatitis B virus? ☐ Yes ☐ No

Please attach copy of front and back of patient’s insurance card(s)

Prior DMARD’s and length of treatment: _________________________________________________________________

Injection training needed: ☐ Yes ☐ No

Expected First Dose Date: ______________

Insurance Company Name: _______________________________________

☐ Actemra

☐ Xeljanz® (tofacitinb)

Insurance Company Phone: ______________________________________

(tocilizumab)

Policy holder: __________________________________________________

☐Inject 162 mg SC every week (>/= 100 kg)

5 mg PO twice daily

☐ Xeljanz XR® (tofacitinb)

Policy holder Employer: __________________________________________

☐Inject 162 mg SC every other week (<100 kg)

Relationship to Patient: __________________________________________

☐Infuse _______ mg/kg IV over 1 hour every 4 weeks

11 mg PO once daily

☐ Cimzia

ID# ___________________________Group# ________________________

(certolizumab pegol)

RxBIN: _______________________RxPCN: ________________________

Initial Dose: ☐400mg SC @ 0, 2, 4 weeks prefilled syringe

☐400mg SC @ 0, 2, 4 weeks lyophilized powder vial (administered in office)

Prescriber Information

Maintenance Dose: ☐ 400mg SC every 4 weeks ☐200mg SC every 2 weeks ☐Prefilled Syringe ☐Vial

☐ Enbrel

(etanercept)

Practice/ Organization Name: _____________________________________

Dose: ☐ 50mg SureClick

☐ 50mg Prefilled Syringe

☐ 25mg Prefilled Syringe

☐ 25mg Vial

Dispense: ☐ Inject SC once per week

☐Inject SC twice per week

☐ (JIA) inject 0.8mg/kg, max 50mg/week

Physician Name: _______________________________________________

☐ Humira

(adalimumab)

Address:______________________________________________________

Dose: ☐40mg/0.8ml Pen

☐40mg/0.8ml Prefilled Syringe

City: _______________________State: ______________ Zip: ___________

Dispense: ☐ Inject SC once per week

☐ Inject SC twice per week

☐Other: _________________________

Phone#:________________________Fax#: __________________________

☐ Orencia

(abatacept

)

DEA#______________________NPI#______________________________

☐ Inject 125mg Prefilled Syringe SC once weekly

License#:__________________Medicaid UPIN#:______________________

☐ Infuse IV over 30 minutes every 2 weeks for 3 doses. Starting at week 8, infuse over 30 minutes every 4 weeks

Physician Specialty: _____________________________________________

☐500mg (pat. <60kg)

☐750mg (60-100kg)

☐1000mg (>100kg)

☐10mg/kg if less than 75kg (JA)

Date Shipment Needed: ___________________________________________

☐ Remicade

(infliximab)

Infuse IV over 2 hours as directed

☐Patient

☐Prescriber

☐Infusion Clinic

Ship to:

Dose: ☐3mg/kg @ 0, 2, 6 weeks

☐3mg/kg every 8 weeks

Shipment Address: ____________________________________________________

☐5mg/kg @ 0, 2, 6 weeks then every 6 weeks thereafter (Ankylosing Spon.)

Attn: _______________________________________________________________

☐10mg/kg @ 0, 2, 6 weeks then every 6 weeks thereafter

City: ______________________State: ____________________ Zip:____________

☐Other dosing: _______________________________________

If shipped to the physician’s office, physician accepts on behalf of patient for administration in office.

☐ Rituxan

(rituximab)

Infuse 1000mg IV bolus on day 1 and 15 every 6 months.

Privacy & Confidentiality of Information Notice: This communication may contain non-public, confidential, or legally

☐ Simponi

☐ Simponi Aria

(golimumab)

privileged information intended for the sole use of the designated recipient(s). If you are not the intended recipient, or

☐ Inject 50mg SC once per month

☐Infuse 2 mg/kg IV over 30 minutes; repeat dose at

have received this communication in error, please notify the sender immediately by reply email or by telephone at the

☐ 50mg SmartJect™ ☐ 50mg prefilled syringe

week 4 and then every 8 weeks thereafter

number stated above and delete all copies of this communication, including any attachments, without reading them or

saving them to disk. If you are the intended recipient, you must secure the contents of this communication in

Quantity Prescribed: ☐QS 30 days ☐Other: ____Refills Authorized:☐ 0 ☐1 ☐2 ☐3 ☐ 6 ☐1 yr ☐Other:____

accordance with all applicable state or federal requirements related to the privacy and confidentiality of information,

including the HIPAA Privacy guidelines.

Physician Signature (no stamps): ____________________________Date:__________________

ENVISIONSPECIALTY EFRA12192016

Rheumatology Prescription And Enrollment Form Orchard Specialty

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