RHEUMATOLOGY ENROLLMENT FORM

Form Name

E-Prescribing is encouraged for quicker turnaround time for our patients.

See our e-prescribe information below!

PATIENT INFORMATION

Patient Name:*

Date of Birth:*

Date

MaleFemalePrefer Not to SayOther

Address

Street Address Line 2

CityState

Zip

Phone Number:*

Alt. Phone Number:

Allergies:*

If no known drug allergies, please put N/A

Language:

Height:

Weight:

SSN:

Patient’s HomePrescriber OfficeAlternative Address:

Alt. Address

Street Address

Street Address Line 2

CityState

Zip Code

PRESCRIBER INFORMATION

Prescriber :*

Provider PIN:*

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:*

Phone Number:*

Fax Number:

Practice Name:

Office Contact:

Practice Address

Street Address

Street Address Line 2

CityState

Zip Code

CLINICAL INFORMATION

Please upload all relevant and available chart notes including lab results:

Diagnosis/ICD -10:

Fracture History
Site blanks Date Date
Site Date Date

MethotrexateOther

Length of treatment:

Reason for discontinuing:

YesNo

ANC Score: blanks/mm3
Platelet Count: blank/mm3

YesNo

PRESCRIPTION INFORMATION

Please select a medication first, then complete and required Dose, Directions, Quantity and Refills

Actemra® Dose:

162 mg prefilled syringe

Once a week (> 100kg)Every other week (< 100 kg)

2 PFSEvery other week (< 100 kg)

200 mg prefilled syringe200 mg autoinjector

Benlysta® Directions:

Inject 200 mg Sub-Q once weekly

Quantity:

4 PFS

Cimzia® Dose:

200 x 2 prefilled syringe

Quantity:

(Initial) 1 starter pack

(Maintenance) 1 kit

Initial: Inject 400 mg Sub-Q at week 0, 2, and 4Maintenance: Inject 400 mg Sub-Q once every 4 weeks ORMaintenance: Inject 200 mg Sub-Q once every 2 weeks

150 mg/mL Sensoready pen150 mg/mL prefilled syringe

With a loading dose: Inject 150 mg Sub-Q at week 0, 1, 2, 3 and 4 then every 4 weeks thereafterWithout a loading dose: Inject 150 mg Sub-Q every 4 weeks

Cosentyx® Qty (with loading dose):

4 PFS/pens

Cosentyx® Qty (without loading dose):

1 PFS/pen

25 mg powder vial25 mg prefilled syringe50 mg Sureclick50 mg prefilled syringe

Enbrel® Qty

4 PFS/pens

Enbrel Directions:
Inject 50 mg Sub-Q once a week Inject _ mg Sub-Q once a week (0.8 mg/kg)

(Input mg:blanks)

40 mg pen40 mg prefilled syringe

Inject 40 mg Sub-Q every other weekInject 40 mg Sub-Q once a week

2 PFS/pens4 PFS/pens

200 mg prefilled syringe150 mg prefilled syringe

Inject 200 mg Sub-Q every other weekInject 150 mg Sub-Q every other week

Kevzara® Qty

2 PFS

Orencia Dose:
125 mg prefilled syringe
125 mg autoinjectgtor
__ mg prefilled syringe
(Please provide mg blank )

Orencia Directions:
Inject      mg Sub-Q once a week (weight-based dosing)

Orencia Quantity:
4 PFS

Starter Pack
Directions: Titration: take 1 tablet on day 1, then twice daily as directed
Qty: 1 starter pack

Bridge Pack
Directions:
Take 30 mg by mouth once daily   Take 30 mg by mouth twice daily
Qty: 28 tablets

30 mg tablets
Directions: Take 1 tablet by mouth twice daily (Titration Date:   Date   )
Qty: 60 tablets

50 mg SmartJect 50 mg prefilled syringe

Directions: Inject 50 mg Sub-Q once a month as directed
Qty: 1 PFS

45 mg prefilled syringe (< 100 kg) 90 mg prefilled syringe (> 100 kg)

Directions: Inject contents of 1 syringe Sub-Q initially and 4 weeks later, and then every 12 weeks
Qty: 1 PFS

Xeljanz Dose: 5 mg tablets

Directions: Take 1 tablet by mouth twice daily

Qty: 60 tablets

Xeljanz XR Dose: 11 mg tablets

Directions: Take 1 tablet by mouth daily with or without food

Qty: 30 tablets

Other Dose:


Directions:


Qty:

Refills

Comments

PRESCRIBER SIGNATURE

Please indicate substitution preferences, 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.

Product substitution permittedDispense as WrittenTherapeutic substitution permitted

Prescriber Signature

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.