Lumizyme and Myozyme Prior Authorization Form/ Prescription Date: ___________ Date Medication Required:____________ Ship to: Physician Patient’s Home Other __________ Phone: (855) 304-5580 Fax: (855) 521-1728 Patient Information Last Name: First Name: Middle: Address: DOB: ____/____/_____ City: Daytime Phone: State: Evening Phone: Sex: Male Zip: Female Insurance Information (Attach Copies of cards) Primary Insurance: Secondary Insurance: ID # Group # ID # Group # City: State: City: State: Physician Information Name: Specialty: Address: Phone # ( NPI: City: ) Secure Fax #: ( State: ) Zip: Office contact: Prescription Information MEDICATION STRENGTH DIRECTIONS QUANTITY REFILLS Lumizyme Myozyme Primary Diagnosis Primary ICD-9/ICD-10 Code: ___________________________ Pompe Disease Other: __________________________________________ Clinical Information INITIAL THERAPY ***** Please submit supporting clinical documentation***** CONTINUATION OF THERAPY; Therapy start date: __________________________ 1. How was the diagnosis confirmed? Indicate all that apply, or mark "None of the above" Acid a-glucosidase (GAA) assays confirming low acid a-glucosidase (GAA) activity Acid a-glucosidase (GAA) activity testing in fibroblast DNA testing for acid a-glucosidase (GAA) mutation None of the above 2. In case of anaphylaxis, severe allergic reaction, or acute cardiorespiratory failure, will appropriate medical support be readily available when the drug is administered? Yes No 3. Does the patient have evidence of cardiac hypertrophy? Yes No Lumizyme 4. Does the patient have infantile-onset Pompe disease? Yes No Myozyme 5. Does the patient have late (non infantile-onset) Pompe disease? Physician’s Signature ________________________________________________ Date: ________________________ DAW
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