Inflammatory Bowel Disease Specialty Medication
Statement of Medical Necessity
Please complete this form (PRINT or Type) entirely and fax it to the number below.
Be sure to enclose any necessary documentation, labs, insurance cards, etc.
Patient Demographics
First Name
Last Name
Address
Address 2
City
State
Zip
Insurance Information
Date of Birth
SS#
Work Phone
Cell Phone
Email
Allergies
Please include copies of the patient’s insurance/drug benefit cards (front and back) to expedite benefit clearance.
Insurance Name
Group Number
Employer
Prescriber Information
Doctor Name
NPI
Address
Address 2
City
State
Zip
Clinical Information Diagnosis
K50.00
K50.019
K50.018
K50.10
Height
Policy Number
Policy Holder
Ins. Phone
DEA
LIC
Work Phone
Fax
Email
Office Notes
K50.118
K50.119
Other:
*See Reverse Side
Has the patient been treated previously for this condition?
Yes
Weight
Medications on
PPD Performed Date:__/___/__
Yes
No
Other Notes
Requested Medication (Fill out form or attach Rx)
Medication
Strength
200 mg/ml Prefilled Syringe
Cimzia ®
200 mg Lyophilized Powder
Humira ®
40mg/0.8ml Pen
Humira® Crohn’s
40mg/0.8ml Pen x6 (Crohn’s Starter Kit)
40mg/0.8ml Prefilled Syringe
starter kit
Remicade ®
100 mg Vial
Simponi™
Stelara® Crohn’s
K50.80
K50.818
100mg/1ml SmartJect AutoInjector
100mg/1ml Prefilled SYR
90mg/0.5mL prefilled syringe *(Maintenance dosing only)
Medications Failed
Results:
Negative
Directions
Quantity
Initial Dose Inject 400mg SC at weeks 0, 2, and 4,
then:
Maintenance Dose: 200mg SC every other week
OR
400mg SC every 4 weeks
Inject 40 mg SC every OTHER week
Inject 40 mg SC ONCE a week
Inject 160 mg (4 pens) SC Day 1 or
Inject 40mg (2 pens) Day 1 and Day 2 then
Second Dose is 2 weeks later (Day 15) of 80 mg (2
pens)
IV
mg at 0, 2, and 6 weeks (induction)
IV
mg every 8 weeks (maintenance)
IV
mg every
weeks
Inject 100mg SC ONCE a month
Initial 4 Week
supply
4 Week supply
Inject 90 mg (1 pen) SC 8 weeks after infusion then
continue every 8 weeks
Other:
Physician Signature
Delivery Needed By
Positive
No
Refills
4 week supply
Other:
Other:
# of vials
4 week supply
Other:
16 wk supply
Other:
Date
Deliver Medication to:
Patients Home
Physician’s Office
Other:
By signing below, I authorize Noble Health Services (“Noble”) to: Collect my health condition and prescription information from my doctor, healthcare provider, health insurer or pharmacist in order to ensure its accuracy and
completeness and to communicate to the patient support program of the pharmaceutical manufacturer (the “Program”); and contact my insurer, other potential funding sources, social workers, patient advocacy organizations,
and patient assistance programs on my behalf to determine if I am eligible for assistance. I hereby authorize my doctor, healthcare provider, health insurer or pharmacist to provide my health condition and prescription
information to Noble and to the Program. I understand that I may revoke this authorization at any time by sending a letter to Noble at 6040 Tarbell Road Syracuse, NY 13206
Patient’s Signature
Important Notice: This communication contains information that is confidential and protected from disclosure. If the reader of this message is not the intended recipient, employee or agent responsible for delivering the
message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please reply to the
sender that you have received the message in error and destroy this copy.
Fax completed form to (888) 842-3977,
Or call (888)843-2040 with questions. Thank you for using Noble Health Services.
Specialty Medication
Enrollment Form
Ask us about custom office forms
Fax the front side of completed form to (888) 842-3977
NDC-10 Code
Diagnosis Description
K50.00
Crohn's disease of small intestine without complications
K50.011
Crohn's disease of small intestine with rectal bleeding
K50.012
Crohn's disease of small intestine with intestinal obstruction
K50.013
Crohn's disease of small intestine with fistula
K50.014
Crohn's disease of small intestine with abscess
K50.018
Crohn's disease of small intestine with other complication
K50.019
Crohn's disease of small intestine with unspecified complications
K50.10
Crohn's disease of large intestine without complications
K50.111
Crohn's disease of large intestine with rectal bleeding
K50.112
Crohn's disease of large intestine with intestinal obstruction
K50.113
Crohn's disease of large intestine with fistula
K50.114
Crohn's disease of large intestine with abscess
K50.118
Crohn's disease of large intestine with other complication
K50.119
Crohn's disease of large intestine with unspecified complications
K50.80
Crohn's disease of both small and large intestine without complications
K50.811
Crohn's disease of both small and large intestine with rectal bleeding
K50.812
Crohn's disease of both small and large intestine with intestinal obstruction
K50.813
Crohn's disease of both small and large intestine with fistula
K50.814
Crohn's disease of both small and large intestine with abscess
K50.818
Crohn's disease of both small and large intestine with other complication
K50.819
Crohn's disease of both small and large intestine with unspecified complications
K50.90
Crohn's disease, unspecified without complications
K50.911
Crohn's disease, unspecified, with rectal bleeding
K50.912
Crohn's disease, unspecified, with intestinal obstruction
K50.913
Crohn's disease, unspecified, with fistula
K50.914
Crohn's disease, unspecified, with abscess
K50.918
Crohn's disease, unspecified, with other complication
K50.919
Crohn's disease, unspecified, with unspecified complications