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

2743 W. 15th St., Plano, TX 75075Ph: 877-868-4110 Fax: 877-868-4144

INJECTABLE LIST

BetamethasoneAcetate/Phospate (Soluspan)6mg/ml P/F

2ml vial5ml vial10ml vial

Size

Betamethasone Sodium Phospate12mg/ml P/F

2ml vial (min 20 vials)5ml vial (min 6 vials)

Size

Chondroitin / Glucosamine / DMSO

2ml vial (min 3 vials)Size

Hyaluronidase150u/ml P/F

10ml vial preservative freeSize

Dexamethasone (Decadron equiv.)P/F same price as Triamcinolone(same min. quantities applyTriamcinolone Acetonide P/F 40mg/ml P/F

1ml vial (min 20 vials)2ml vial (min 20 vials)

Size

Methylprednisolone Suspension40mg/ml and 80mg/ml P/F

2ml vial (min 20 vials)5ml vial (min 6 vials)10ml vial (min 6 vials)

Size

Ondansetron2mg/ml

2ml vial (min 50 vials)Size

Midazolam* 1-5mg/ml

1-2ml vial (min 50 vials)Size

Fentanyl*50mcg/ml

2ml vial (min 50 vials)Size

Sodium Bicarbonate 4.2% - 8.4%

Size 50ml vial (min 12 vials)Lidocaine 1-2%

Size 50ml vial (min 12 vials)

PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI

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: ________________________ 714.0 Rheumatoid ArthriƟsSecondary Diagnosis: _______________________ ICD9 Code: ________________________ 720.0 Ankylosing SpondLJůŝƟƐ Previous Treatment: ____________________________________________________________ 733.0 Osteoperosis Previous Treatment Outcome:____________________________________________________ 696.0 PsorŝĂƟc ArthriƟs Is ƉĂƟĞŶƚ taking Methotrexate? YES NO 714.3 Juvenile Idiopathic ArthriƟs 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) MEDICATION STRENGTH DIRECTIONS QNTY. REFILL

ΎWƌĞƐĐƌŝďĞƌ Signature: ______________________________________________ Date: ___________________

Actemra

Cimzia

Enbrel

Humira

80mg/4mL 200mg/10mL 400mg/20mL

______mg/kg

IniƟal Dose: 4mg/kg every 4 weeks Maintenance Dose: 8mg/kg every 4 weeks Other:

STARTER KIT 200mg/1mL PreĮůůed Syringe 400mg vial

IniƟal Dose: 400mg sub-q day 1. Week 2, week 4 Maintenance Dose: 200mg sub-q QOW Maintenance Dose: 400mg sub-q every 4 weeks Other: __________________________________

50mg/ml Sureclick Autoinjector 50mg/ml PreĮůůed Syringe 25mg/0.5ml PreĮůůed Syringe 25mg Vial

50mg sub-q QW 25mg sub-q BIW (72-96 hrs apart) Other: ___________________________________

40mg/0.8ml Pen 40mg/0.8ml PreĮůůed Syringe 20mg/0.4ml PreĮůůed Syringe

40mg sub-q QOW 20mg sub-q QOW Other:

Kineret 100mg PreĮůůed Syringe 100mg sub-q QD

Orencia

250mg Vial _________________

125mg Orencia sub-q

Infuse ____mg at wks 0,2, 4 then every 4 wksOther: _________________________________________________ ŌĞr single IV iniƟal dose, inject 125mg sub-q within a day followed by 125mg sub-q QW 125mg sub-q QW

Remicade 100mg Vial mg/kg

Rituxan 100mg/10ml vial 500mg/50ml vial

Infuse 2 doses of 1000mg separated by 2 weeks Other: _______________________________________

Simponi 50mg/0.5ml PreĮůůed SmartJect 50mg/0.5ml PreĮůůed Syringe

Inject 50mg/0.5ml sub-q once monthly Other: ___________________________________

RHUMFRMVS.912

ARTHRITIS / RHEUMATOLOGYWƌĞƐĐƌŝƉƟŽŶ Form

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

Treating Patients SpecialShip to: PaƟent Home MD KĸĐe

/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange

FAX TO: (888) 294-9434

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

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

NEUROLOGY & PAIN REFERRAL FORM

PRESCRIPTION

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SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽdžLJͲͲ'ůƵĐŽƐĞнϯйĐLJĐůŽǀŝƌ

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NEUROPATHIC PAIN & ANTI - INFLAMMATORY SPRAY:ΎƉƉůLJϯ;ϭŵůͿƐƉƌĂLJƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϰƟŵĞƐĚĂŝůLJͲ&ůƵƌďŝƉƌŽĨĞŶϳϱйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнDĞŶƚŚŽůϯйн>ŝĚŽĐĂŝŶĞϮϬйнD^KͲ<ĞƚĂŵŝŶĞϮϬйнDĞƚŚLJů^ĂůŝĐLJůĂƚĞϯϬйнDĞŶƚŚŽůϯйнD^KͲdƌĂŵĂĚŽůϮϬйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнWƌŝŽůŽĐĂŝŶĞϮϱйн>ŝĚŽĐĂŝŶĞϭϮϱйнDĞŶƚŚŽůϯйMIGRAINE HEADACHE:ΎWůĞĂƐĞƐƉĞĐŝĨLJĚŽƐĞĂŶĚĨƌĞƋƵĞŶĐLJͲƌŐŽƚĂŵŝŶĞϭŵŐĂīĞŝŶĞϭϬϬŵŐĞůůĂĚŽŶŶĂϭϬŵŐĂƉƐƵůĞͲƌŐŽƚĂŵŝŶĞdĂƌƚƌĂƚĞϮŵŐ^ƵďůŝŶŐƵĂůdĂďůĞƚƐ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

Cream Size (Pump): 75gm (Seventy-Five Grams)ϭϬϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ'ƌĂŵƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ^ŵĂůůĞƐƚ^ŝnjĞϱϬŐŵ;&ŝŌLJ'ƌĂŵƐͿ

Spray Size:ϲϬŵů;^ŝdžƚLJŵŝůůŝůŝƚĞƌƐͿϭϮϬŵů;KŶĞŚƵŶĚƌĞĚdǁĞŶƚLJŵŝůůŝůŝƚĞƌƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

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