RHEUMATOLOGY REFERRAL FORM Patient Information

S P E C I A LT Y
P H A R M AC Y
Patient
Information
Transforming lives one patient at a time
RHEUMATOLOGY REFERRAL FORM
Patient Information
Date:
Patient SS#:
Patient’s First Name:
Address:
Best Phone #:
DOB:
Caregiver:
Patient has a negative TB test result.
Date of test:
INSURANCE INFORMATION:
Diagnosis:
Patient’s Last Name:
City/County:
Alternate Phone #:
Allergies:
Female
State:
Zip:
PLEASE FAX COPY OF INSURANCE CARD (FRONT & BACK)
714.0 Rheumatoid Arthritis
696.0 Psoriatic Arthritis
Other:
Clinical
Male
Phone: 813-960-2020
Fax: 813-549-3810
Toll Free: 877-436-2020
720.0 Ankylosing Spondylitis
Date of Diagnosis or Years with Disease:
Acetaminophen, ibuprofen, naproxen sodium, or other OTC pain relievers
Prior Medications:
Calcipotriene
Celebrex
Corticosteroids
Indocin
Methotrexate
Naproxen
Additional justification for drug
Humira
Enbrel
Azulfidine
Other Clinical Information/Comments:
General: Is patient also taking methotrexate?
Does patient have a latex allergy?
Yes
No
Yes
No
Has Hepatitis B been ruled out or treatment been initiated?
Yes
No
If No, has treatment been initiated?
Yes
No
Medication
Quantity
Refills
1 Kit
0
3 Kits
0
Dose/Strength
Directions
Starter Dose
200mg/ml Prefilled Syringe Starter Kit
NDC: 50474-0710-81
Prescription
Cimzia®
200mg Lyophilized Powder (LYO)
Maintenance Dose
200mg/ml Prefilled Syringe
200mg Lyophilized Powder (LYO)
400mg Sub-Q every 4 weeks
200mg Sub-Q every 2 weeks
Enbrel®
50mg/ml Sureclick™ Autoinjector
50mg/ml Prefilled Syringe (PFS)
25mg Vial (inj. supplies incl)
Inject 50mg Sub-Q ONCE a week
Humira®
40mg/0.8ml PEN
40mg/0.8ml Prefilled Syringe
Inject 40mg Sub-Q every OTHER week
Inject 40mg Sub-Q ONCE a week
4-week
supply
250mg Vial (IV use only)
Loading Dose: 10mg/kg IV x 1 dose, then 125mg
Sub-Q weekly, start within 24hrs of IV dose
1 dose
125mg/mL Prefilled Syringe
125mg Sub-Q ONCE a week
4-week
supply
Simponi®
50mg/0.5ml SmartJect™ Autoinjector
50mg/0.5ml Prefilled Syringe
Inject 1 single-use SmartJect™ Autoinjector Sub-Q once monthly
Inject 1 single-use Prefilled Syringe Sub-Q once monthly
1 (one)
Xeljanz®
5mg
Take 1 tablet by mouth twice daily
Orencia®
Patient Support
Initial dose of 400mg Sub-Q at weeks 0, 2, and 4
4-week
supply
Inject 25mg Sub-Q TWICE a week
0
60
Enbrel Injection Training or Nurse Support: ENBREL Support™ RN to provide education & training for Sub-Q injection
Nurse Training Needed
Humira Injection Training or Nurse Support: *Physician Signature required for Injection Training*
myHUMIRA Nurse (RN) visit to provide education & training for Sub-Q injection of Humira including PRN administration by the Nurse (RN)
Patient’s Home or Clinic Site
Physician’s Office
No Nurse
Simponi Injection Training or Nurse Support: SimponiOne RN to provide education & training for Sub-Q injection
Patient Support:
Nurse Training Needed
I authorize Superior Specialty Pharmacy to enroll me in the pharmaceutical company-assisted patient support program, corresponding with my prescribed therapy for purposes of
receiving additional services such as, but not limited to injection training. I further authorize Superior Specialty Pharmacy to release and communicate to the corresponding manufacturer the minimum
necessary information about my health condition and prescription(s) to: coordinate the delivery of products and services available through writing by sending a letter to Superior Specialty Pharmacy, 5416
Town & Country Blvd., Tampa, FL 33615. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment from the pharmacy. However, I will not be
enrolled in the service program listed above. A copy of this authorization will be utilized with the same effectiveness as an original.
Patient Signature (required):
Prescriber
Information
4-week
supply
Date Shipment Needed:
Ship to Other:
Physician Name (please print):
Phone #:
Office Address:
Date:
Ship to:
Patient
Fax #:
City:
Physician/Clinic
Contact Name:
NPI #:
State:
Zip:
I authorize Superior Specialty Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process.
Physician’s Signature:

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