•
•
ax:
Toll Free: 877.849.9591
REFERRAL FORM
Ship To: D Patient
D Physician/Clinic
• D Rheumatoid Arthritis D Ankylosing Spondylitis D Juvenile RA (JIA) D other
• Severity index: D Mild
D Severe
D Moderate
• Has patient been treated previously for this condition? D No DYes
Address:
Medication/therapy failed (length of therapy):
City, State, Zip:
Alt. Phone:
Home Phone:
0
Patient SS#:
a::
0
D No
• Will patient terminate current therapy upon start of new prescription? DYes D No
• How long should the patient wait before starting the new drug therapy?
Allergies:
D Female
Gender: D Male
Primary Insurance:
• Other medications patient is currently taking including OTC medications with
dosage and direction (or fax medication profile):
�
Phone:
ID#:
Secondary Insurance:
•
Therapies:
• Is patient currently in therapy? DYes
Type / Medications:
DOB:
z
Iz
Rx: D New D Refill
Date Shipment Needed:
Patient's Full Name:
z
15211 Vanowen St. Suite 301 Van Nuys, CA 91405
Has patient received a PPD (tuberculosis) Skin Test? DYes
Phone:
ID#:
PLEASE FAX COPY OF INSURANCE CARD (FRONT & BACK)
MEDICATION
ICD-10 Code:
Results:
DOSE/STRENGTH
D Actemra
D 162mg/0.9ml PFS
D Cimzia Initial Dose
D 200mg Starter Kit (contains 6, 200mg PFS)
D Cimzia Maintenance
D 2 x 200mg Prefilled Syringe
Treatment
D No
QTY.
SIG
D Inject 1 syringe SC every week
D Inject 1 syringe SC every other week
4-week
supply
D Inject 400mg SC once, then repeat at weeks 2 and 4
4-week
supply
D 200mg SC ONCE every TWO weeks
D 400mg SC ONCE every FOUR weeks
4-week
supply
D 150mg Lyophillized Powder SDV
D Induction Dose: 150 mg SC at Weeks 0, 1, 2, 3 and 4
and once every 4 weeks hereafter
D Maintenance Dose: 150 subq every 4 weeks
D Other
D Enbrel
D 50mg/ml SureClick™ Autoinjector
D 50mg/ml Prefilled Syringe
D 25mg Prefilled Vial
D Inject 50mg SC ONCE a week
D Inject 25mg SC TWICE a week, 72 to 96 hours apart
D Other:
4-week
supply
D Humira
D 40mg/0.8ml Pen
D 40mg/0.8ml Prefilled Syringe
D Inject 40mg SC every OTHER week
D Inject 40mg SC ONCE a week
4-week
supply
D Orencia
D 125mg/ml Prefilled Syringe (4 syringes)
D Inject 125mg SC ONCE weekly
D T itration Pack or Date starter pack was provided
D Take as instructed according to the package
instructions presented for 28 days
D 1 tablet twice daily
D 150mg/ml Sensoready Pen
D Cosentyx
D 150mg/ml Prefilled Syringe
D Otezla
/
_
030 mg
/
_
#55
#60
D 100mg Vial # of Vials
D Rituxan
D 100mg Vial # of Vials
D Simponi
D 50mg/0.5ml Prefilled Syringe
D 50mg/0.5ml Autoinjector
D Inject 50mg SC ONCE a month
D Simponi, Aria
D 50mg/4ml single use Vial
D Infuse
D Infuse
D Other
D Xeljanz
D 5mg tablets
D Take 5mg by mouth TWICE daily
#60
D Xeljanz XR
D 11mg tablets
D Take 11mg by mouth ONCE daily
#30
I.LIO
m�
Address:
a:c:C
City,
State,
Zip:
(.) a:
:E
u,
I.LIO Phone:
D::LL
a..z
NPI#:
(Please Print):
Physician's Signature:
4-week
supply
mg at week 0, 4 then every 8 weeks
mg every 8 weeks
I
Physician's Name
No
Refills
4-week
supply
D Remicade
Z
a:
REFILLS
# of Prescriptions:
License#:
DEA#:
Fax:
Contact Name:
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 name 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 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 named addressee.
-This 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 the patients.
-The prescriber attests that he/she has advised the patient with the option of choosing a pharmacy of his/her choice.