Phone: (877) 868-4110 Fax: (877) 868-4144

Prescribers and Staff

YOUR ONE-STOP SOLUTION

Our goal is to service all of the needs of your office and your patients.

• A member of our team will fax prescription and patient status updates throughout the prescription process• Prior authorizations to initiate treatment• Re-­Authorization to prevent therapy interruption• Cost management•• No cost for delivery to patient home or your office• Injection training for self injectable medications at patient home or in your office• Disease and treatment education prior to therapy initiation• Ongoing side effects management• Customize patient monitoring• Refill reminders and coordination•• Retail prescriptions to ensure patients have ONE PHARMACY• Infusion & Compounding services available

AMERICAN SPECIALTY PHARMACY is able to assist you. We are a SpecialtyPharmacy with retail stores with the ability to fill ALL of your patient’s medications.

Attached you will find a Prescription Referral Form for use with specific chronicillnesses. If your patients also need other medications not listed, just send the

prescription along with it and we’ll take care of that too!

For more information please call or email:

Phone: (877) 868-­4110 | Fax: (888) 294-­9434 | Email: info@americanspecialtypharmacy.com

PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX

www.AMERICANSPECIALTYPHARMACY.com

OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:

Compounded & Specialty MedicationsDurable Medical Equipment (DME)

Nutritional SupplementationWorkers’ Compensation Prescriptions

Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOUOur customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire

process. From contacting your insurance carrier to automatic re lls and overnight delivery.

We look forward to serving you and meeting all of your pharmacy needs.

www.AMERICANSPECIALTYPHARMACY.com

HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm

COMPLIMENTARY DELIVERYAll deliveries are delivered straight to

your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLSYour re lls are lled automatically based on

your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION2743 West 15th Street

Plano, TX 75075P: 877-868-4110 . F: 877-868-4144

EMAILinfo@americanspecialtyrx.com

At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe

and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or

unavailable medications to meet speci c patient needs.

We o er a full line of Professional Quality Vitamins, Nutritional Supplements, OTC Medications, Everyday

Prescriptions, Medical Equipment & Specialty Medications.

www.AMERICANSPECIALTYPHARMACY.com

PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟent demographiĐs)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________INSURANCE INFORMATION (Use this area or aƩĂĐŚ Đopy of insuranĐe Đard(s)

Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________

MEDICAL ASSESSMENT (Use this area or ĂƩĂĐŚ ƉĂƟent labs and other authorizaƟon informaƟon)

Primary Diagnosis: _________________________ ICD9 Code: ________________________Secondary Diagnosis: _______________________ ICD9 Code: ________________________ Previous Treatment(s): ________________________________________________ Date of Diagnosis: __________________ Previous Treatment Outcome:___________________________________________ Is ƉĂƟĞŶƚ taking Methotrexate? YES NO Has ƉĂƟent tried and failed oral systemic DMARD agents? YES NO Is ƉĂƟĞnt at risk for HepaƟƟƐ B? YES NO Has TB test been done? YES NO Results if YES: ________________________________________________________________ Is ƉĂƟĞŶƚ diagnosed with heart failure? YES NO Is ƉĂƟĞŶƚ diagnosed with lymphoma? YES NO

PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s) LIST OF MEDICATIONS:

Prescriber Name: ________________________________________ NPI#: ______________________ Contact:__________________________________ Address:__________________________________ City: _________________ State: _________ ZIP: ____________ Ph: _________________________ Fax: ________________________________ DEA#: ________________________ St. License: ___________________________________ Email: ________________________________________________________________

ΎWƌĞƐĐƌiber Signature: _____________________________________________________ Date: _____________

PRESCRIBER INFORMATION

RFDRMVS.12

PULMONARY ARTERIALHYPERTENSION FORM

Treating Patients Special Ship to: PaƟent Home MD KĸĐe MD KĸĐe FIRST FILL ONLY

/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange

DIAGNOSIS & CLINICAL INFORMATION:Diagnosis: Pulmonary Arterial Hypertension Familial PAH (416.0 ICD-9) Idiopathic PAH (416.0 ICD-9)ƐƐŽĐŝĂƚĞĚǁŝƚŚ;ĐŚĞĐŬŽŶĞͿŽŶŐĞŶŝƚĂů,ĞĂƌƚ;/ͲϵͺͺͺͺͺͺͿŽŶŶĞĐƟǀĞdŝƐƐƵĞ;ϳϭϬϬ/ͲϵͿ HIV (ICD-9 _______ ) Scleroderma (ICD-9 ______ ) Other: __________________________ (ICD-9 ______ )ŝĂďĞƟĐzĞƐEŽ

Adcirca® ZĞǀĂƟŽΠ Tracleer® Letairis Other: _____________

Dose / Strength:

Sig / ŝƌĞĐƟŽŶƐ

ReĮůl(s): ____________ YƵĂŶƟƚLJ ____________ Date: _______________

This is a list of the most common Specialty Pulmonary Arterial HypertensionŵĞĚŝĐĂƟŽŶƐ American Specialty Pharmacy is available to Įůů all of your ƉĂƟĞŶƚƐ ƉƌĞƐĐƌŝƉƟŽŶ needs. Please include any other medicaƟŽŶƐ your ƉĂƟĞŶƚ needs.

FAX TO: (888) 294-9434

CALL;ϴϳϳͿϳϱϯ-ϲϴϳϳ FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com

PATIENT INFORMATION (Use this area or aƩach ƉĂƟĞnt demographics)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs.

INSURANCE INFORMATION (Use this area or ĂƩĂch copy of insurance card(s)

Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________

MEDICAL ASSESSMENT (Use this area or aƩach ƉĂƟĞnt labs and other authorizĂƟŽn informaƟon)

Primary Dx: ______________________ ICD9 Code: ___________ Secondary Dx: ______________________ ICD9 Code: ___________New Transplant? YES NO Transplant date: ___________________ Hospital Name: _____________________________________

PRESCRIPTION INFORMATION *(Use this area or aƩĂch copy of RX(s)

*Prescriber Signature: ______________________________________________ Date: ___________________

TRNSPLTFRMVS.912

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________

Treating Patients Special CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com

Ship to: PaƟent Home MD KĸĐe

/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to ArrangeCYSTIC FIBROSIS

WƌĞƐĐƌŝƉƟŽŶ&Žƌŵ

Trio Nebulizer: Dispense one unit with necessary supplies and replace the heads every 90 days

dŽďƌĂŵLJĐŝŶ/ŶŚĂůĂƟŽŶ^ŽůƵƟŽŶtŝƚŚdƌŝŽEĞďƵůŝnjĞƌ/>hddKϰϬŵŐŵůϱϬŵŐŵůYdz ͺͺͺͺͺĚĂLJƐƐƵƉƉůLJZĞĮůůͺͺͺͺͺͺ

/ŶŚĂůĞϭϱϬŵŐ/ƵƐŝŶŐĂdƌŝŽEĞďƵůŝnjĞƌ;ϮϴĚĂLJƐŽŶϮϴĚĂLJƐŽīͿKƚŚĞƌͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

TOBI 300mg/5ml/ŶŚĂůĞϯϬϬŵŐ/ƵƐŝŶŐĂWZ/>W>h^EĞďƵůŝnjĞƌ;ϮϴĚĂLJƐŽŶϮϴĚĂLJƐŽīͿYdz ͺͺͺͺͺͺĚĂLJƐƐƵƉƉůLJZĞĮůůͺͺͺͺͺͺͺ Other: __________________________________________________________

WZ/>W>h^EĞďƵůŝnjĞƌŝƐƉĞŶƐĞϭƵŶŝƚǁŝƚŚĂůůŶĞĐĞƐƐĂƌLJƐƵƉƉůŝĞƐĂŶĚƌĞƉůĂĐĞĞsŝůďŝƐƐŽŵƉƌĞƐƐŽƌĮůƚĞƌĞǀĞƌLJϲŵŽŶƚŚƐ

ŽůŝƐƟŵĞƚŚĂƚĞ/ŶŚĂůĂƟŽŶ^ŽůƵƟŽŶϭϱϬŵŐsŝĂůƐ Ydz ͺͺͺͺͺͺĚĂLJƐƐƵƉƉůLJZĞĮůůͺͺͺͺͺͺ/ŶŚĂůĞϳϱŵŐŽĨĚŝůƵƚĞĚŽůŝƐƟŵĞƚŚĂƚĞ/ƵƐŝŶŐĂdZ/KŶĞďƵůŝnjĞƌ;ϮϴĚĂLJƐŽŶϮϴĚĂLJƐŽīͿ Other: ___________________________________________________________________ ͻŝůƵƟŽŶŝŶƐƚƌƵĐƟŽŶƐ Dilute with 6ml of Sterile Water and 2ml of NS (use 4ml and discard remaining - Dilute to 75mg/4ml Other: ____________________________________________________________

,LJƉĞƌƚŽŶŝĐ^ĂůŝŶĞ ϳй^ŽůƵƟŽŶϱй^ŽůƵƟŽŶ ϯй^ŽůƵƟŽŶ ŝƌĞĐƟŽŶƐ/ŶŚĂůĞͺͺͺͺͺŵůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺYdz ͺͺͺͺͺͺĚĂLJƐƐƵƉƉůLJZĞĮůůͺͺͺͺͺͺͺͺͺ

WƵůŵŽnjLJŵĞϮϱŵŐϮϱŵů ŝƌĞĐƟŽŶƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺYdz ͺͺͺͺͺĚĂLJƐƐƵƉƉůLJZĞĮůůͺͺͺͺͺͺͺůďƵƚĞƌŽůϬϴϯŵŐŵů ϬϰϮŵŐŵů ϬϮϭŵŐŵů ŝƌĞĐƟŽŶƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺYƚLJͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺyŽƉĞŶĞdž ϬϯϭŵŐϯŵů ϬϲϯŵŐϯŵů ϭϮϱŵŐϯŵůŝƌĞĐƟŽŶƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺYƚLJͺͺͺͺͺͺͺZĞĮůůͺͺͺͺͺͺ OTHER: ____________________________________________________________________________________________

www.AMERICANSPECIALTYRX.com

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