Psoriasis/Psoriatic Arthritis/Hidradenitis Suppurativa Referral Form Publix Specialty Pharmacy (#3212) PATIENT INFORMATION PATIENT’S FIRST NAME ______________________________________ PATIENT’S LAST NAME ADDRESS _________________________________________________________________ PRIMARY PHONE NUMBER ______________________________________________ DEA# CITY ________________________________________ SHIP TO: £ PATIENT £ FAX NUMBER _____________________________________ PRESCRIBER’S OFFICE, PLEASE PROVIDE APPOINTMENT DATE: ___/___/______ £ _______ /_______ /_______ STATE _______________ £ MALE £ FEMALE ZIP _________________________ CAREGIVER NAME ________________________________________________________ ____________________ ADDRESS _________________________________________________________________ ______________________________________ DATE OF BIRTH CITY ___________________________________ ALT. PHONE NUMBER ______________________________________________ PRESCRIBER NAME ______________________________________ OFFICE PHONE NUMBER ____________________________________ 7616 Southland Blvd, Suite 112 Orlando, FL 32809 Phone: 855-797-8254 Fax: 863-413-5723 NPI# ___________________ STATE _______________ ZIP _________________________ OFFICE CONTACT ______________________________________ OTHER ______________________________________________________________________ INSURANCE £ COPY OF PRESCRIPTION INSURANCE CARD(S), FRONT AND BACK, ATTACHED __________ ___________________ GROUP# __________ RX GRP ___________________ _____________________________________ INSURED ____________________________ ID# ________________ ______________________________________ RX BIN ____________________________________ RX PCN ______________________ SECONDARY INSURANCE ____________________________________ INSURED ____________________________ ID# ________________ PHONE# ___________________ RX DRUG CARD NUMBER ______________________________________ RX BIN ____________________________________ RX PCN ______________________ PRIMARY INSURANCE GROUP# PHONE# ___________________ RX DRUG CARD NUMBER RX GRP CLINICAL £PSORIASIS (PsO) £ PSORIATIC ARTHRITIS (PsA) £ HIDRADENITIS SUPPURATIVA (HS) £ OTHER: ________________________________________ DIAGNOSIS: DIAGNOSIS CODE: ______________ PRIOR THERAPY: ________________________________________________________________________________________________________________________________________________________________________ ALLERGIES: ____________________________ MEDICATION £ Cimzia (certolizumab pegol) £ Cosentyx (secukinumab) WEIGHT: __________ KG/LB TB TEST? DOSE/STRENGTH £ 200 mg/mL prefilled syringe (PFS) £ 200 mg vial £ 150 mg/mL Sensoready pen £ 150 mg/mL PFS £ YES £ NO RESULT: £ POS £ NEG DIRECTIONS Initial Dose (for PsA): £ 400 mg (2 x 200 mg) SC at weeks 0, 2, and 4 Maintenance Dose: £ 400 mg (2 x 200 mg) SC every 4 weeks £ 200 mg SC every 2 weeks Initial Dose: £ For PsO: 300 mg (2 x 150 mg) SC on weeks 0, 1, 2, 3, and 4 £ For PsA: 150 mg SC on weeks 0, 1, 2, 3, and 4 Maintenance Dose: £ 300 mg (2 x 150 mg) SC every 4 weeks £ 150 mg SC every 4 weeks £ Enbrel (etanercept) £ Humira (adalimumab) £ 50 mg/mL SureClick £ 50 mg/mL PFS £ 25 mg/0.5mL PFS £ 25 mg vial Initial Dose (for PsO): £ 50 mg SC TWICE a week (72 – 96 hours apart) Maintenance Dose: £ 50 mg SC ONCE a week £ 25 mg SC ONCE a week £ 40 mg Pen £ 40 mg PFS £ Other: _______________ Initial Dose: £ For PsO: 80 mg (2 x 40 mg) SC on day 1, then 40 mg every other week starting day 8 £ For HS: 160 mg (4 x 40 mg) SC on day 1, then 80 mg (2 x 40 mg) on day 15 Maintenance Dose: £ 40 mg SC every OTHER week £ 40 mg SC every week £ Other: _____________________ £ Otezla (apremilast) £ Simponi (golimumab) £ Stelara (ustekinumab) DATE OF TEST: QUANTITY £ 1 Starter kit = 6 PFS £ 3 vial kits = 6 vials £ 10 pens or PFS £ 5 pens or PFS 0 0 £ 2 pens or PFS £ 1 pens or PFS 2 cartons = 8 £2 £ Other _______ 1 carton = 4 £ 1 PsO Starter pack = 4 Pens £ 2 cartons = 4 PFS £ 1 HS Starter pack = 0 6 Pens £ 3 cartons = 6 PFS £ 1 carton = 2 Pens or 2 PFS £ 2 cartons = 4 Pens or 4 PFS £ Other: __________ £ 30 mg tablet £ 50 mg/0.5 mL SmartJect £ 50 mg/0.5 mL PFS Inject SC every 4 weeks £ 45 mg/0.5 mL PFS £ 90 mg/1 mL PFS Initial Dose: £ Inject SC on day 1 and 4 weeks later on day 29 2 PFS Maintenance Dose: £ Inject SC every 12 weeks 1 PFS and 30 mg tablets) REFILLS £ 1 PFS kit = 2 PFS £ 1 vial kit = 2 vials Initial dose (for psoriasis): 1 tab PO on day 1 then BID as directed Maintenance Dose: £ 1 tab PO BID £ 1 tab PO ONCE a day (for severe renal impairment) £ Starter Pack (contains 10 mg, 20 mg, ________ / ________ / ________ 28 Day Starter pack = 55 tablets 0 £ 60 tablets £ 30 tablets 1 SmartJect or 1 PFS 0 £ Other I authorize Publix Pharmacy representatives to act on behalf of the prescriber to initiate and complete the insurance prior authorization process. __________________________________________________ PRESCRIBER SIGNATURE £ Dispense as written £ Substitution allowed ______ /_____ /_______ DATE For Pharmacy Use Only Patient Contact yes/no __/___/___by___ Pick Up at Store________/Mail Scanned in to ______on __/___/___by___ RP1101 (8-16)
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