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EnrollmentForm
FAX: 1-855-322-2087PHONE: 1-855-443-9944NPI: 1417216128
Deliver Medications To: Patient's Home Doctor's Office Date Needed By: __________ Inj. Training/Admin. Y N
PATIENT DEMOGRAPHICS
Last Name: First Name: Date of Birth:
Street Address: City:
Home Phone: Cell Phone: Work Phone:
State: Zip:
Prescription Insurance: PLEASE ATTACH A COPY OF THE FRONT AND BACK OF THE PATIENT'S CARD
Primary Prescription Insurance: ___________________________________
Patient ID/Policy Number: ________________________________________
Rx BIN: __________________
Patient Rx Group Number: ________________________________
Rx PCN: __________________
PATIENT CLINICAL INFORMATION/HISTORY: (PLEASE ATTACH A COPY OF PATIENT'S RECENT CHART NOTES, PATHOLOGY AND LABS)
Diagnosis: _______________
PRESCRIPTION INFORMATION
Boniva injection
Forteo
Prolia
Reclast
DRUG STRENGTH DIRECTIONS QUANTITY REFILLS
PRESCRIBER INFORMATION
Prescriber Name:
Street Address:
Office Phone:DEA:Physician Signature: _____________________________
Facility Group or Hospital:
City:Office Fax: Office Contact:NPI: UPIN:
Date: _____________________________________
State: Zip:
ICD-10 Code: _______________
Disease State Description:Postmenopausal osteoporosis with fracture risk (female)Postmenopausal osteoporosis prophylaxisHypogonadal osteoporosis with high fracture risk (male)Glucocorticoid-induced osteoporosis treatment/prophylaxisPaget's diseaseOther: _____________________________________________
Date of Diagnosis: ______________________________________Test Results:
Serum calcium _____________________Scr/CrCl ___________________________BMD______________________________T score ____________________________
WNL:YesYesYesYes
NoNoNoNo
Weight__________kg/lbs Height__________cm/in BSA________m2
Allergies:_________________________________________________
Fracture History:___________________________________________
Prior Failed Therapies:
Concomitant Medications:__________________________________
Additional Comments: _____________________________________
Treatment Start Date: ___________Treatment End Date: __________
Actonel (risedronate)Fosamax (alendronate)Reclast (Zoledronic Acid Injection)
Boniva (ibandronate)Prolia (denosumab)
OSTEOPOROSIS
Inject 20mcg subcutaneous once daily
NEEDLES 31 gauge 5mm 6mm 8mm
600mcg/2.4ml
Use with Forteo Delivery Device as directed
60mg
5mg
Inject 60mg subcutaneous every 6 months
Infuse 5mg IV once a year
1 device(4-week supply)3 device(12-week supply)
4-week supply12-week supply
1 vial
3mg every 3 months administered intravenously overa period of 15 to 30 seconds
3mg PFS
"By signing I hereby authorize Encompass Rx, LLC and its pharmacists, technicians and other employees and agents to disclose, share and submit patient information to health insurers, HMOs, employer group health plans, governmentalhealth programs, or other payors, for the purpose of satisfying such payor's prior authorization requirements with respect to the medication being prescribed for the treatment of our mutual patient."
NEEDLES 31 gauge 5mm 6mm 8mm Use with Tymlos Delivery Device as directed 4-week supply12-week supply
Tymlos 2000mcg/mL Inject 80mcg subcutaneous once daily
1 device(4-week supply)3 device(12-week supply)