IBD Department Contact Information Direct Department Phone: 602-354-3399 Direct Department Fax: 602-334-1764 E.H.R GENERAL FAX: 602-896-0454
INFLAMMATORY BOWEL DISEASE (IBD) Arizona’s Local Pharmacy
PRESCRIPTION ENROLLMENT FORM
PATIENT INFORMATION
PRESCRIBER INFORMATION
Patient Name
Prescriber’s Name
DOB Weight
SSN#
Male
Height
Female
Phone
Cell phone
License# NPI
DEA
Group/Hospital
Address State
City
Zip
Primary Insurance
Address
Bin#
City, State, ZIP
Primary Insurance Phone Group/Policy#
English
Spanish
Other
Bin#
Secondary Insurance Secondary Insurance Phone
Phone
Fax
Contact Person
Phone
Supervising Physician Name
MEDICAL AND DIAGNOSIS INFORMATION (Please attach Clinical Notes for Pharmacist and Nurse Case Management Review) Diagnosis:
k50.00
k50.010
k50.80
Does patient have a latex allergy? Humira
Prior (FAILED) Therapy:
Yes
k50.90
k51.00
k51.50
k51.80
k51.90
Other
No
Simponi
Remicade
Cimzia
Methotrexate
Corticosteroids
Other (please list): TB/PPD Test Given?
Yes
No Date of Negative TB test:
If no, has treatment been started? Prescription Remicade
Humira
Cimzia
Simponi®
300mg in a single dose vial in individual carton
DIRECTIONS Induction Dose: IV at 5mg/kg (Dose= Maintenance Dose: IV at 5mg/kg (Dose= Other:
QUANTITY mg) at 0, 2, and 6 weeks. mg) every 8 weeks.
No
REFILLS
# of 100mg vials
Recommended dosage in UC and CD: 300 mg infused IV over 30 minutes at 0, 2 and 6 weeks, then every 8 weeks thereafter.
Crohn’s Starter Package
Induction Dose: Inject subcutaneously 160mg (4 pens) on day 1, then 80mg (2 pens) on day 15, then maintenance dosing.
40mg Self Injectable Pen
Maintenance Dose: Inject subcutaneously 40mg (one pen) every other week.
40mg Prefilled Syringe
Maintenance Dose: Inject subcutaneously 40mg (one syringe) every other week.
Cimzia Starter Kit
Induction Dose: Inject subcutaneously 400mg (2 injections) on day 1, and at weeks 2 and 4.
200mg/1 mL Prefilled Syringe 200mg vial
Maintenance Dose: Inject subcutaneously 400mg (2 injections) every 4 weeks.
100mg/1ml Prefilled syringe 100mg/1ml SmartJect® Autoinjector
Yes
No
DOSE/STRENGTH 100mg vial mg/kg
Entyvio
Yes
Hepatitis B ruled out?
1 package
1 kit (6 prefilled syringes)
Induction Dose: Inject 200mg (2x100mg syringes/pens) SC at week 0; then inject 100mg SC at week 2 Maintenance Dose: Inject 100mg SC every 4 weeks
Other
Patient Support Programs: Please sign and date below to enroll in the pharmaceutical company assisted patient support program. Date:
Patient Signature: Prescriber Signature: Prescriber, please sign and date below: Substitution Permissible
Date
Dispense Rx as written
Date
To Prescriber: By signing above or otherwise utilizing our service, you name and authorize Valley of The Sun Pharmacy as your designated agent for the limited purposes of taking all steps and signing all related documents on behalf of you that is necessary in dealing with medical, prescription companies, insurance companies, as well as co-pay assistance programs, to obtain prior approval to fill or continue to fill your prescription(s) as it relates to the patient on this form.
IMPORTANT NOTICE: This fax is intended to be delivered only to the named addressee and contains confidential information that may be protected health information under federal and state laws. If you are not the intended recipient, do not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. If you receive this communication in error, please notify sender immediately by calling 602-896-0454
Consent Form ENROLLMENT IN INFLAMMATORY BOWEL DISEASE (IBD) TREATMENT PROGRAM I understand that my physician advises that I received treatment for Inflammatory Bowel Disease (IBD) using:
1. 2. 3. I understand that close follow-up of my condition is very important and that attendance at all office visits is MANDATORY for treatment to continue. I understand that my COMPLIANCE with the advised doses and timing of medication is very important and I need to notify my physician of any changes that have been made. I understand the timing of any follow-up labwork and other testing is critical in determining my response to treatment. By agreeing to this treatment I understand that I may develop side effects or experience injury to one or more body organs. I also understand that I will be required to have regular blood work and possibly other tests to monitor my treatment and screen for possible side effects. There are no guarantees that the treatment will be successful. I must also consent to periodic home health visits from a nurse to evaluate medications compliance. I agree to work with my specialty pharmacy for the delivery of my medication which may be designated by insurance. My provider may also request regular drug and alcohol screening during my therapy and I must also comply with this to continue with therapy. I have and will abstain from illicit drugs and alcohol use.
PATIENT AGREEMENT TO STATEMENTS BELOW Initial
Description I understand the side effects that occur with I am aware of the side effects that may be serious and need to be reported immediately to my attending physician. I know that if I have severe side effects in evenings or on weekends, I can call to 602-354-3399 and ask to speak with a pharmacist, call my physician, or go to the emergency room. I understand that I will need to abstain from ALCOHOL and/or ILLICIT DRUG while on treatment and for up to 12 months after treatment is completed. I understand that I must not get pregnant or father a child while taking my treatment and for the designated time that my physician indicates. If I am sexually active, I will use 2 forms of birth control while on treatment and for six months afterward. I am responsible for making sure I do not run out of medication and that I need to call Valley of the Sun Pharmacy at 602-354-3399 for re-orders. I will take my medication exactly as directed and it is part of my responsibility to read the package insert provided by the pharmaceutical company. I will notify my treating provider if I miss or stop doses of my medication. I am responsible for going to the laboratory, other testing and clinic visits as prescribed by my attending health care provider.
I agree to this therapy and responsibilities of me while on therapy. I have asked all questions and these have been answered completely prior to my starting therapy. By consenting to this treatment program I am authorizing Valley of the Sun Pharmacy to have access to all of my medical records, laboratory and other test results as needed in order to monitor my disease states.
Patient’s Name: Patient’s Signature:
DOB: