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
PULMONARY ARTERIAL HYPERTENSION FORM
Treating Patients Special PATIENT INFORMATION (Use this area or
CALL FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com
American Specialty to Arrange
Ship to:
Pa ent Home MD e MD e FIRST FILL ONLY
ent 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 a
opy of insuran e ard(s)
Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or
Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________
ent labs and other authoriza on informa on)
Primary Diagnosis: _________________________ ICD9 Code: ________________________ Secondary Diagnosis: _______________________ ICD9 Code: ________________________ Previous Treatment(s): ________________________________________________ Date of Diagnosis: __________________ Previous Treatment Outcome:___________________________________________ NO Is taking Methotrexate? YES NO Is nt at risk for Hepa B? YES NO Has ent tried and failed oral systemic DMARD agents? YES NO Results if YES: ________________________________________________________________ Has TB test been done? YES YES NO Is diagnosed with lymphoma? YES NO Is diagnosed with heart failure? DIAGNOSIS & CLINICAL INFORMATION:
Diagnosis: Pulmonary Arterial Hypertension Familial PAH (416.0 ICD-9) Idiopathic PAH (416.0 ICD-9) HIV (ICD-9 _______ )
Scleroderma (ICD-9 ______ )
PRESCRIPTION INFORMATION *(Use this area or
LIST OF MEDICATIONS:
Other: __________________________ (ICD-9 ______ )
opy of RX(s)
Adcirca速
Tracleer速
Letairis
Other: _____________ This is a list of the most common Specialty Pulmonary Arterial Hypertension American Specialty Pharmacy is available to all of your needs.
Dose / Strength: Sig /
Re l(s): ____________
____________
Date: _______________
iber Signature: _____________________________________________________
Please include any other medica your needs.
Date: _____________
PRESCRIBER INFORMATION Prescriber Name: ________________________________________ NPI#: ______________________ Contact:__________________________________ Address:__________________________________ City: _________________ State: _________ ZIP: ____________ Ph: _________________________ Fax: ________________________________ DEA#: ________________________ St. License: ___________________________________ Email: ________________________________________________________________
FAX TO: (888) 294-9434
RFDRMVS.12
CYSTIC FIBROSIS
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)
Trio Nebulizer: Dispense one unit with necessary supplies and replace the heads every 90 days
TOBI 300mg/5ml Other: __________________________________________________________
Other: ___________________________________________________________________ Dilute with 6ml of Sterile Water and 2ml of NS (use 4ml and discard remaining - Dilute to 75mg/4ml Other: ____________________________________________________________
OTHER: ____________________________________________________________________________________________
*Prescriber Signature: ______________________________________________
Date: ___________________
Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________ TRNSPLTFRMVS.912
www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston