Workers Comp | Litigation | Motor Vehicle | Personal Injury | LOP | Auto Injury
Plano Ph: (214) 919-2090 Fax: (214) 919-2091 San Antonio Ph: (210) 615-7400 Fax: (210) 615-7401
Denton Ph: (940) 383-1222 Fax: (940) 383-1444 El Paso Ph: (915) 860-7225 Fax: (915) 860-7320
Miami Ph: (305) 856-0070 Fax: (305) 856-0072
Houston Tyler
WE HELP SET UP YOUR PRESCRIPTION
HASSLE FREE WE INSURANCE WECALL CALLYOUR YOUR ATTORNEY& &ATTORNEY INSURANCE
INJURED PERSON
WE DELIVER RIGHT TO YOUR DOOR
phone calls and paperwork”
Assistance is only a Phone Call away!
WE TAKE CARE OF YOUR REFILLS Open 7 Days a Week Corporate Office
Contact Us at: info@AmericanSpecialtyPharmacy.com lop@AmericanSpecialtyPharmacy.com Tel: (877) 753-6877 Fax: (888) 966-0188
2743 West 15th Street, Plano, TX 75075 Toll Free: 877-753-6877 www.AmericanSpecialtyPharmacy.com
PLEASE HAVE THE FOLLOWING INFORMATION AVAILABLE:
• Name, address and phone number.
• Employer & Insurance carrier name, address, phone number, adjuster name and claim number. • Doctor’s name, phone number and being prescribed.
Tel: (877) 753-6877 Fax: (888) 966-0188
CONVENIENCE IS OUR BUSINESS About Us • American Specialty Pharmacy is one of the leading providers of pharmaceu services in the United States. Our knowledge and exper in the business makes us recognizable in the industry. pharmaceu
• At American Specialty Pharmacy, we are
dedicated to address the well-being of our customers. We are driven by our commitment to be the best and strive to bring the best services and solu to all our clients.
solu
r all your prescrip
• Our dedicated staff works diligently to reduce the stress, put into handling each claim.
• Assist with complicated claim forms • No Out-of-pocket expenses* • FREE Home Delivery Service Assis ng the
.
• By allowing us to manage your clients
department will promptly and carefully a end all phone calls, faxes, and requests.
American Specialty Pharmacy is able to assist you in resolving all injury claims. •Handle all Insurance Paperwork •Hassle Free Delivery •Drug Formulary Management &
• We will ensure that your clients' have all their prescrip completely sa
.
t and are
Data Maintainance & Side-Effect
•
Management
the client's needs.
We can also fill your regular prescriptons with a simple transfer.
*On approved claims
For the Physicians
orney
• Our experienced customer service
t that is
• We will CUSTOMIZE our services to fit
Our professional and courteous staff will ensure that your prescrip in a .
prescrip providing the best possible care for their other medical needs.
Why choose us?
• We are a FULL SERVICE, ONE STOP
Taking care of the t
*On approved claims
•Compounding & Infusion Services (supplements available upon request)
PLANO | EL PASO | SAN ANTONIO HOUSTON | TYLER | DENTON | MIAMI www.AMERICANSPECIALTYPHARMACY.com PHONE: (877) 753-6877 FAX: (888) 966-0188
www.AMERICANSPECIALTYRX.com
PAIN, SCAR, & WORKERS COMPENSATION Today’s Date
Treating Patients Special
NEW PATIENT
CURRENT PATIENT
First Middle Last Patient Name _______________________________________________ DOB ____________ Weight _______ Male Female Street Address ______________________________________________________________________________________________ Apt # _________ City ___________________________________________ State ____________________ Zip _________________ Daytime Ph ____________________________ Evening Ph ___________________________ Cell ___________________________ Email ________________________________________________ Allergies _____________________________________________
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS PRESCRIPTION FORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:
*Dosing = Apply 3 (4.5gm) pumps to affected area(s) 3 times daily (1pump = 1.5gm) C-Flurbiprofen 10% + Gabapentin 10% + Lidocaine 10 % + Ketamine10 %
SCAR CREAMS
* Apply 3 Pumps (4.5gm) an even layer of Cream, and gently massage the cream on scar two times daily (Do not apply to open wounds.) C-Fluticasone 1% + Levocetrizine Dihydrochloride 2% + Lidocaine 5% + Pentoxyfyline 0.5% + Gabapentin 10% ( in a Silicone Based Protective Gel)
Cream Size (Pump): 150gm (One Hundred Fifty Grams)Refills: _______ 200gm (Two Hundred Grams) Refills: _______ 1 (One) 2 (Two) 3 (Three)
___________________________________________________________________________ QTY: _________ __________________________________________________________________________________
Refills:________
ADDITIONAL INJURED WORKER MEDICATION
Medrox Patches (Capsaicin 0.038% + Menthol 5%) (For Pain) *Dosing = Apply 1 - 3 patches to affected area daily QTY: 30 (Thirty) 60 (Sixty) 90 (Ninety) Refills: 1 (One) 2 (Two) 3 (Three)
ANXIETY: GABAdone 60
For the dietary management of sleep disorders associated with anxiety Take one (1) or two (2) capsules at bedtime to initiate sleep QTY: ______ Refills: _____
1 (one)
2 (two)
3 (three)
OSTEOARTHRITIS:
*Dosing = Take 1 capsule 3 times daily Synovacin (Glucosamine Sulfate Capsules 500mg) Genicin (Glucosamine Sulfate Capsules 500mg) QTY: 90 (Ninety) 180 (One-Hundred Eighty) Refills: 1 (One) 2 (Two) 3 (Three)
STOOL SOFTNER:
Laxacin (Sennosides 8.6mg + Docusate 50mg) Promolaxin (Docusate 100mg) 100
Refills:
Theramine
120
Trepadone
120
For dietary management of pain syndromes that include chronic pain,fibromyalgia, neuropathic pain, and inflammatory pain Take two (2) capsules twice daily or as needed under phtysician supervision For the dietary management of pain associated with osteoarthritis Take two (2) capsules twice daily
QTY: ______ Refills: _____
1 (one)
2 (two)
3 (three)
SLEEP DISORDER: Somnicin (Melatonin + 5-Hydroxytryptophan + Tryptophan) *Dosing = Take 1 tablet 30 minutes prior to bedtime SentraPM (Choline Bitartrate, Glutamic Acid, Acetyl L-Carnitine,
Ginkgo Biloba, Griffonia Extract (5HTP 95%), Hawthorn Berry and Cocoa)
*Dosing = Take with full glass of water (8oz). Do not take medicine more than directed.
QTY:
PAIN & INFLAMMATION
1 (One)
2 (Two)
*Dosing = Take 1 or 2 capsules 30 minutes prior to bedtime QTY: 30 (Thirty) 60 (Sixty) 90 (Ninety) Refills: 1 (One) 2 (Two) 3 (Three)
3 (Three)
By signing this form and utilizing our services, you are authorizing American Specialty Pharmacy and it’s employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies.
Prescriber’s Signature (signature required. NO STAMPS) ____________________________________________________ Date _____________________
IMPORTANCE NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is confidential privileged, proprietary or exempt from disclosure under applicable law. If you are not the named addressee, you should 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. Medicare and Medicaid or another state funded program will not cover above mentioned compounds. Co-payments due at dispensing of the medication
Fax completed form to AMERICAN SPECIALTY PHARMACY at (214) 919-2091
HOW IT WORKS: AUTO INJURY, WORKERS COMP
behalf
Upon receiving the prescription, we call you to schedule delivery (If you don’t hear from us within 24 hours, please contact our pharmacy)
(If applicable)
We file the insurance claim on your or bill your attorney
Automatic prescription refills (if necessary)
no out-of-pocket expenses*
FREE Delivery within 24 hours &
*On approved claims
We can also fill your regular prescriptions with a simple transfer
www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston