Phone: (877) 868-4110 Fax: (877) 868-4144
Prescribers and Staff
YOUR ONE-STOP SOLUTION AMERICAN SPECIALTY PHARMACY is able to assist you. We are a Specialty Pharmacy 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 chronic illnesses. If your patients also need other medications not listed, just send the prescription along with it and we’ll take care of that too!
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 • P rior authorizations to initiate treatment • R e-Authorization to prevent therapy interruption • C ost management • N o cost for delivery to patient home or your office • I njection training for self injectable medications at patient home or in your office • D isease and treatment education prior to therapy initiation • O ngoing side effects management • C ustomize patient monitoring • R efill reminders and coordination • R etail prescriptions to ensure patients have ONE PHARMACY • I nfusion & Compounding services available 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
We look forward to serving you and meeting all of your pharmacy needs. OUR PRODUCTS & SERVICES
We are a full service pharmacy that specializes in: Compounded & Specialty Medications Durable Medical Equipment (DME) Nutritional Supplementation Workers’ Compensation Prescriptions Everyday Prescriptions
WE TAKE THE BURDEN OFF OF YOU
Our 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.
www.AMERICANSPECIALTYPHARMACY.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.
COMPLIMENTARY DELIVERY All deliveries are delivered straight to your door within 24 hours at no out-of-pocket cost to you.
AUTOMATIC REFILLS
Your re lls are lled automatically based on your prescription or physician’s approval. It is not necessary to reorder!
PLANO LOCATION
2743 West 15th Street Plano, TX 75075 P: 877-868-4110 . F: 877-868-4144
info@americanspecialtyrx.com
HOURS OF OPERATION Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm
www.AMERICANSPECIALTYPHARMACY.com
American Specialty to Arrange
Ship to:
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
Treating Patients Special PATIENT INFORMATION (Use this area or
Pa ent Home Pick up at ASP
MD
e
nt demographi s)
Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or
opy of insuran
Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or
ard(s)
Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________
h pa ent labs and other authoriz
Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________ PRESCRIPTION INFORMATION *(Use this area or
opy of RX(s)
Anemia Aranesp ® (darpopoetin alfa)
Epogen ® (epoetin alfa)
Procrit® (epoetin alfa)
SIG: Inject dose ____________ mcg/kg or _____________mcg Route:
IV
Dispense quan
SC
Phenylketonuria Kuvan Dose: 10mg/kg body weight
Other: _____ mg/kg
Frequency _______________________
____________
Re ls _______________
Neutropenia Rx:
Leukine® (sargramos n) (liquid) (lyophilized) 250 mcg
Neulasta® (pegfilgrastim)
500 mcg/ml 500 mcg
Soliris ™ 300mg/30ml Sig: _________________________________________________
6 mg/0.6 ml prefilled Syringe
Neupogen® (filgrastim)
300 mcg/ml vial 300mcg/0.5 prefilled Syringe 480 mcg/ml vial 480mcg/0.8 prefilled Syringe SIG: Inject Dose: ____________ mcg/kg or _____________mcg/m2 Route: IV SC Continuous SC Dosing Directions(Include daily, weekly, cyclic, one-time, duration of txt. etc.) _____________________________________________________________________ _____________________________________________________________________ Dispense Quantity: _____________ Refills:_______________ Supplies (if needed per dose):
1 ml syringe
25G 5/8” needle 7G 5/8” needle 22G 1” mixing needle Sterile Water 10 ml 271/2G 5/8”admin. needle (Pediatrics Only)
3 ml syringe
Renvela 800mg Tab Sensipar 30 60
90
Sig: _________________________________________________
NOTES: ____________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________
PRESCRIBER INFORMATION
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________
FAX TO: (888) 294-9434
HIVFRMVS.12
TRANSPLANT Form
Treating Patients Special
American Specialty to Arrange
Ship to:
CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
PATIENT INFORMATION (Use this area or a ach
Pa ent Home
MD
e
nt demographics)
Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs.
INSURANCE INFORMATION (Use this area or
ch copy of insurance card(s)
Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________
MEDICAL ASSESSMENT (Use this area or a ach
Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________
nt labs and other authoriz
n informa on)
Primary Dx: ______________________ ICD9 Code: ___________ Secondary Dx: ______________________ ICD9 Code: ___________ New Transplant? YES NO Transplant date: ___________________ Hospital Name: _____________________________________
PRESCRIPTION INFORMATION *(Use this area or a
ch copy of RX(s)
Cellcept
250mg 500mg 200mg/ml – 175mL/BO Other: ___________________
Myfo
180mg 360mg Other: ____________________
Prograf
0.5mg 1mg 5mg Other: _____________________
Qnty:
0.5mg 1mg 2mg 1mg/ml – 60mL/BO Other: _____________________
Qnty:
Rapamune Neoral
25mg 100mg 100mg/ml – 50mL/BO
Qnty:
Gengraf
25mg 100mg Other: ___________________
Sandimmune
0.5mg 1mg 5mg Other: ___________________
Valcyte
450mg Other: ___________________
Qnty:
Azithromycin
250mg 500mg Other: ___________________
Qnty:
Myclex
10mg Other: ___________________
Qnty:
___________
Dose:
*Prescriber Signature: ______________________________________________
Qnty: Re : Qnty: Re : Re :
Re : Re : Qnty: Re : Qnty: Re : Re : Re : Re : Qnty: Re :
Date: ___________________
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________ TRNSPLTFRMVS.912
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