IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyoneother than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read orretained by anyone other than the named addressee, except by express authority of the sender to the named addressee.
X X
Dermatology Enrollment Form Phone: 602-971-6950 / 877-971-3001 Fax: 877-552-5698
PATIENT INFORMATION PRESCRIBER INFORMATION (Complete the following or include demographic sheet) Prescriber’s Name:
Patient Name: State License #: NPI #: Address: DEA #:
City, State, Zip: Group or Hospital: Primary Phone: DOB: Address:
Alternate Phone: Gender: Male Female City, State Zip:
Last 4 digits of SS#: Phone: Fax:
Primary Language: Contact Person: Phone:
PRESCRIPTION INFORMATION
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Vasco Rx Pharmacy can accept only original prescription drug orders from patients, and faxed prescriptions from the prescribing practitioners.
Drug Directions and Quantity Refills
Enbrel®
Sensoready Pen
Pre-filled Syringe
INNNITIAAAL: Inject 300 mg SQ on week 0, 1, 2, 3 and 4 (Quantity: 10)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 300 mg SQ every 4 weeks (Quantity: 2)INNNITIAAAL: Inject 150 mg SQ on week 0, 1, 2, 3 and 4 (Quantity: 5)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 150 mg SQ every 4 weeks (Quantity: 1)
Humira®
Simponi®
SureClick Pen 50mg
Pre-filled Syringe
25mg 50mg
Vials 25mg
Otezla®
New Refill Ship by: ____/____/____ SHIP TO: Patient’s Home Doctor’s Office Other ___________________
Cosentyx®
DATE
Inject 50 mg SQ twice weekly 72-96 hours apart (Quantity: 8) Inject 50 mg SQ every week (Quantity: 4) Inject 25 mg SQ twice weekly 72-96 hours apart (Quantity: 8)
PPPsoriasis Initial: Inject 50 mg SQ twice weekly (72-96 hours apart) for 3 months (QTY: 8 with 2 refills)
Psoriasis Maintenance: Inject 50 mg SQ weekly (Quantity: 4)
Psoriasis Starter Kit
Pen Pre-filled Syringe
HS Starter Kit
Pen Pre-filled Syringe
INNNITIAAAL: Inject 80 mg SQ on day 1, 40 mg on day 8, then 40 mg every other week (Quantity: 4)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 40 mg SQ every other week (Quantity: 2)
INNNITIAAAL: Inject 160 mg SQ on day 1, then 80 mg on day 15 (Quantity: 6)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 40 mg SQ every week (Quantity: 4)
Take as directed per package instructions (Quantity: 55)14 day titration starter pack sample provided by MD office
Take 30 mg PO twice daily (Quantity: 60) Take 30 mg PO once daily (Quantity: 30) CCContinuation offf Therapy: Yes No
Take 30 mg PO twice daily (Quantity: 28) (12 refills) Take 30 mg PO once daily (Quantity: 28) (6 refills)
28 Day Starter Pack
Maintenance
Bridge Dose Pack
SmartJect® Pen
Pre-filled SyringeInject 50 mg SQ once monthly (Quantity: 1)
Stelara®
INNNITIAAAL: Inject 45 mg SQ on day 0 and day 28 (Quantity: 2)MAAAINNNTEEENNNAAANNNCCCEEE: Inject 45 mg SQ every 12 weeks (Quantity: 1)
INNNITIAAAL: Inject 90 mg SQ on day 0 and on day 28 (Quantity: 2) **WWWeight mmmust be greater thanMAAAINNNTEEENNNAAANNNCCCEEE: Inject 90 mg SQ every 12 weeks (Quantity: 1) or equal to 222222000lbs
Pre-filled Syringe
Weight Required: ______
Taltz® Auto Injector
Pre-filled Syringe
STAAARTINNNG: Inject 160 mg SQ on week 0 (Quantity: 2)INNNDUCCCTIONNN: Inject 80 mg SQ every 2 weeks (weeks 2-12) (Quantity: 2 plus 2 refills)
MAAAINNNTEEENNNAAANNNCCCEEE: Inject 80 mg SQ every 4 weeks (after 12 weeks) (Quantity: 1)
American Academy of Dermatology Consensus Statement on Psoriasis TherapiesPsoriasis is covering greater than 10% of body surface area Psoriasis is on palms, soles, head and neck, or genitalia Psoriasis occurs in conjunction with pain, swelling, or stiffness in joints Psoriasis patient needs more aggressive therapy due to impact on ability to perform daily activities, employment, or interpersonal relationship.
INJECTION TRAININGPatients has received pen and injection training Physician’s office to provide injection training Vasco Rx to coordinate injection training
Prescribing Practitioner
To Prescribing Practitioner: By signing this form and utilizing our services, you are also authorizing Vasco Rx to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies, and co-pay assistance foundations.
page 1 of 2 6/01/2017
Phone: 602-971-6950 / 877-971-3001 Fax: 877-552-5698
PATIENT INFORMATION PRESCRIBER INFORMATION (Complete the following or include demographic sheet) Prescriber’s Name:
Patient Name: State License #: NPI #: Address: DEA #:
City, State, Zip: Group or Hospital: Primary Phone: DOB: Address:
Alternate Phone: Gender: Male Female City, State Zip:
Last 4 digits of SS#: Phone: Fax:
Primary Language: Contact Person: Phone:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Vasco Rx Pharmacy can accept only original prescription drug orders from patients, and faxed prescriptions from the prescribing practitioners.
MEDICAL INFORMATION
***PLEASE FAX COPY OF PRESCRIPTION/MEDICAL CARD, FRONT AND BACK, AS WELL AS ANY CLINICAL NOTES REGARDING THERAPY***
DMARDS: Tried & Failed (Duration):Methotrexate
Soriatane
Cyclosporine
( )
( )
( )
( )
Not Tolerated: Contraindication:
TOPICAL Agents:
Clobetasol
Hydrocortisone
Contraindication:
PHOTOTHERAPY
UVA/ UVB
Patient cannot afford Photosensitivity Risk of Skin Cancer Distance from Office
Tried & Failed (Duration):( )
Not Tolerated: Contraindication:
SPECIALTY Drugs:Enbrel
Humira
Tried & Failed (Duration):( )
( )
( )
Not Tolerated: Contraindication:
Affected Areas
Hands Feet ScalpGroin Nails FaceOther:BSA (% is required): ______%
Date of Diagnosis:
____/____/____
L40.0 Psoriasis Vulgaris (Plaque Psoriasis)
L40.50 Arthropathic Psoriasis, Unspecified (Include failed
NSAIDs: )
L73.2 Hidradenitis suppurativa
Other:
Active TB is ruled out: Yes No Date: ___/___/___
Hep B ruled out/treated: Yes No Date: ___/___/___
Allergies:
Additional Clinical Information:
Tried & Failed (Duration):( )
( )
( )
Not Tolerated:
page 2 of 2 6/01/2017