Cardiovascular Enrollment

CARDIOVASCULAR
Form Name

	Elmsford, NY	Garfield, NJ	NYC, NY
Phone:	914.840.5027	862.225.9422	844.749.6628
Fax:	914.840.5022	862.962.9423	888.966.0647
Email:	Elmsford@ahmarx.com	Garfield@ahmarx.com	NYC@ahmarx.com

Patient Information
Please attached a copy of the patient's insurance card

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Patient Name:
Date of Birth:

MonthDayYear
Date
Sex:

MaleFemale
Address

Address

Street Address Line 2

CityState

Zip
Cell Phone Number:
Home Phone Number:
Language:
Allergies (Required):*
If none, please put N/A
Product Shipping Options:

Patient’s HomePrescriber OfficeAlternative Address:
Alternate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Prescriber Information
Prescriber :*
Prescriber PIN:*
Provider PIN Sub-label: Please provide your verification PIN. For those new to our pharmacy, please put 11111 and we'll reach out to you to set up a PIN.
NPI:*
DEA:
Practice Name:
Office Contact:
Phone Number:*
Practice Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number:

Prescription Information
Medication - Dose

Praluent - 75 mg/mL prefilled pensPraluent - 150 mg/mL prefilled pensRepatha - 140 mg/mL prefilled syringeRepatha - 140 mg/mL SureClickRepatha - 420 mg/mL PushTronex
Praluent 75 mg / 150mg: Directions
Praluent 75 mg / 150mg: Quantity
Praluent 75 mg / 150mg: Days Supply
Praluent 75 mg / 150mg: Refills
Repatha 140 mg - Directions
Repatha 140 mg - Quantity
Repatha 140 mg - Days Supply
Repatha 140 mg - Refills
Repatha 420 mg - Directions
Repatha 420 mg - Quantity
Repatha 420 mg - Days Supply
Repatha 420 mg - Refills

PRESCRIBER SIGNATURE (PLEASE SIGN AND DATE BELOW)
Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms, the receipt and submission of patient lab values and other patient data including pursuing available copay and financial assistance on behalf of my patients. If this pharmacy determines that it is unable to fulfill this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.

Generic substitution permittedTherapeutic substitution PermittedDispense as Written
Comments:
Prescriber Signature:
Signature

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Date

MonthDayYear
Date
CONFIDENTIALITY NOTICE: This form and its contents may contain private and confidential information that is intended for the individual or entity to which it is addressed. Any transmission of this form may contain information that is exempt from disclosure under laws including but not limited to the Health Insurance Portability and Accountability Act (HIPAA). Unless explicitly stated, you are strictly prohibited from disseminating, copying or distributing any material contained within. Violators will be prosecuted to the fullest extent of the law. If you received this communication in error, please notify us immediately and destroy this form and its contents.
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CARDIOVASCULAR

Patient Information

Prescriber Information

Clinical Information

Lab Results

Prescription Information

PRESCRIBER SIGNATURE (PLEASE SIGN AND DATE BELOW)

Prescriber Signature: