Fillable Asthma Enrollment Form Medications A-C

Fill Online, Printable, Fillable, Blank Asthma Enrollment Form Medications A-C Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Asthma Enrollment Form Medications A-C

On average this form takes 27 minutes to complete

The Asthma Enrollment Form Medications A-C form is 3 pages long and contains:

  • 0 signatures
  • 82 check-boxes
  • 69 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Asthma Enrollment Form
Medications A-C
(Cinqair)
Six Simple Steps to Submitting a Referral
1 PATIENT INFORMATION (Complete or include demographic sheet)
Patient Name: _______________________________________Address: ______________________________City, State, ZIP: ______________________________
Preferred Contact Methods
: Phone (to primary # provided below) Text (to cell # provided below) Email (to email provided below)
Note: Carrier charges may apply. If unable to contact via text or email, Specialty Pharmacy will attempt to contact by phone.
Primary Phone: __________________________ Alternate Phone: _______________________DOB: ___________________ Gender:
Male Female
Email: ____________________________________________________Last Four of SSN: ________________Primary Language: ___________________________
2 PRESCRIBER INFORMATION
Prescriber’s Name: ________________________________________________________ State License #: _____________________________________________
NPI #: _______________ DEA #: _______________ Group or Hospital: __________________________________________________________________________
Address: ___________________________________________________________ City, State, ZIP: ______________________________________________________
Phone: _________________________ Fax___________________ Contact Person: __________________________ Contact’s Phone: ____________________
3 INSURANCE INFORMATION
Please fax copy of prescription and insurance cards with this form, if available (front and back)
4 DIAGNOSIS AND CLINICAL INFORMATION
Needs by Date: ______________________________________ Ship to: Patient Office Other: __________________________________________
Diagnosis (ICD-10):
J45.4 Moderate Persistent Asthma J45.5 Severe Persistent Asthma
D72.119 Hypereosinophilic syndrome (HES) M30.1 Eosinophilic Granulomatosis with Polyangiitis (EGPA)
J33.0 Polyp of the nasal cavity J33.1 Polypoid sinus degeneration J33.8 Other polyp of sinus
J33.9 Nasal Polyp, unspecified (indication for dupilumab and omalizumab)
Other Code: __________ Description ________________________
Patient Clinical Information:
Allergies: ________________________________________ Weight: ______lb/kg Height: ______in/cm
IgE Level: __________________
Eosinophil count: ______ Cells/µL Date of test: __/__/____ Number of exacerbations in the last 12 months: ______
5 PRESCRIPTION INFORMATION
MEDICATION STRENGTH DOSE & DIRECTIONS QUANTITY/REFILLS
Cinqair
(reslizumab)
100 mg/10 mL vial
Inject 3 mg/kg once every 4 weeks by IV infusion over 20 to 50 minutes
Include sodium chloride and supplies sufficient for medication days
supply
IV administration/infusion set (0.2micron filter)
IV Cath Insyte autoguard or PIV insertion kit
Ultrasyte needle-free connector (one per vial shipped)
30 mL syringe (one per vial shipped)
50 mL 0.9% NaCl
2 – 10 mL 0.9% NaCl flush
Alcohol swabs
Quantity:
__________ vials
30-day supply
90-day supply
____-day supply
Refills:
1 year
Other: _______
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By signing above, I
hereby authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to payors for the prescribed medication
for this patient and to attach this Enrollment Form to the PA request as my signature.
©2021 CVS Pharmacy, Inc. or one of its affiliates. 75-38688A 11/4/21 Page 1 of 3
Fax Referral To: 1-800-323-2445 Phone: 1-800-237-2767
Email Referral To: Customer.ServiceFax@CVSHealth.com
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
Medications D-W
Asthma Enrollment Form
(Dupixent, Fasenra, Nucala)
Please complete Patient and Prescriber information
Patient Name: _____________________________________________________ Patient DOB: ______________________________________________________
Prescriber Name: _________________________________________________ Prescriber Phone: ________________________________________________
5 PRESCRIPTION INFORMATION
MEDICATION STRENGTH DOSE & DIRECTIONS QUANTITY/REFILLS
Dupixent
(dupilumab)
PFS
100 mg/0.67
mL PFS
200 mg/1.14
mL PFS
300 mg/2 mL
PFS
PEN*
200 mg/1.14
mL pre-filled pen
300 mg/2 mL
pre-filled pen
*Comes in
cartons of 2
Pediatric 15 to <30 kg:
Inject 100 mg SC (one injection) every other week
Inject 300 mg SC (one injection) every four weeks
Pediatric ≥30 kg:
Inject 200 mg SC (one injection) every other week
Adult Initial Dose:
Inject 400 mg SC (2-200 mg injections in different injection sites) initially then
200 mg SC every other week
Inject 600 mg SC (2-300 mg injections in different injection sites) initially then
300 mg SC every other week
Adult Maintenance Dose:
Inject 200 mg (one injection) SC every other week
Inject 300 mg (one injection) SC every other week
Chronic Sinusitis with Nasal Polyposis
Inject 300 mg (one injection) SC every other week
Quantity: _
_
_____
Refills: _________
Fasenra
(benralizumab)
PFS
30 mg/mL
pre-filled syringe
Auto-injector
30 mg/mL
Pen/Self-
administered
Administer 30 mg/mL by subcutaneous injection every 4 weeks for the first 3
doses, followed by injection once every 8 weeks thereafter
Other: Administer ___________________________________
Quantity:
1 PFS/Pen
3 PFS/Pen
Refills:
1 year
Other: ______
Nucala
(mepolizumab)
Vial
100 mg vial
PEN
Auto-injector
100 mg/mL auto-
injector
PFS
100 mg/mL
PFS
SEVERE ASTHMA
Inject 100 mg subcutaneously once every 4 weeks into the upper arm, thigh, or
abdomen
EOSINOPHILIC GRANULOMATOSIS WITH POLYAGNIITIS (EGPA)
Inject 300 mg as 3 separate 100 mg subcutaneous injections once every 4
weeks into the upper arm, thigh, or abdomen
HYPEREOSINOPHILIC SYNDROME (HES)
Inject 300 mg as 3 separate 100 mg subcutaneous injections once every 4
weeks into the upper arm, thigh, or abdomen
Include sterile water and supplies sufficient for medication days supply
No supplies requested (supplies will be sent with shipment unless indicated)
One 10 mL vial sterile water for injection for every vial of Nucala dispensed
Alcohol swabs
3 mL Luer Lock injection syringe
NDL 21G needle for reconstitution
1 mL polypropylene syringe with 21G to 27G x ½” needle for subcutaneous
injection
Quantity:
30-day supply
90-day supply
____-day supply
Refills:
1 year
Other: ______
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By
signing above, I hereby authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to
payors for the prescribed medication for this patient and to attach this Enrollment Form to the PA request as my signature.
©2021 CVS Pharmacy, Inc. or one of its affiliates. 75-38688A 11/4/21 Page 2 of 3
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
Medications X-Z
Asthma Enrollment Form
(Xolair)
Please complete Patient and Prescriber information
Patient Name: _____________________________________________________ Patient DOB: ______________________________________________________
Prescriber Name: _________________________________________________ Prescriber Phone: ________________________________________________
5 PRESCRIPTION INFORMATION
Xolair
(omalizumab)
Vial
150 mg vial kit
PFS
75 mg/0.5 mL pre-
filled syringe
150 mg/1 mL pre-
filled syringe
Every 4 weeks dosing:
Administer 75 mg per dose subcutaneously every 4 weeks
Administer 150 mg per dose subcutaneously every 4 weeks
Administer 225 mg per dose subcutaneously every 4 weeks
Administer 300 mg per dose subcutaneously every 4 weeks
Other: Administer ________ mg per dose subcutaneously every 4
weeks
Every 2 weeks dosing:
Administer 225 mg per dose subcutaneously every 2 weeks
Administer 300 mg per dose subcutaneously every 2 weeks
Administer 375 mg per dose subcutaneously every 2 weeks
Other: Administer ________ mg per dose subcutaneously every 2
weeks
For Xolair Vials only:
Include sterile water and supplies sufficient for medication days
supply
No supplies requested (supplies will be sent with shipment unless
indicated)
One 10 mL vial sterile water for injection for every vial of Xolair
dispensed
Alcohol swabs
Flexible bandages 1” x 3”
3 mL Luer Lock injection syringe
NDL 18G x 1½” Safety Glide needle for reconstitution
NDL 25G x ⅝” Safety Glide needle for subcutaneous injection
Quantity:
30-day supply
90-day supply
____-day supply
Refills:
1 year
Other: ______
I certify that the rationale for Xolair therapy for Allergic Asthma is necessary for this patient and I will be supervising the patient’s treatment accordingly
.
Nursing Medications
Asthma Enrollment Form
(Epipen, Epipen Jr.)
Please complete Patient and Prescriber information
Patient Name: _____________________________________________________ Patient DOB: ______________________________________________________
Prescriber Name: _________________________________________________ Prescriber Phone: ________________________________________________
5APRESCRIPTION INFORMATION
MEDICATION STRENGTH DOSE & DIRECTIONS QUANTITY/REFILLS
Other: ____________ Other: ________________ Other: __________________________________________________________________
Quantity:_______
Refills:_________
Epipen Other: ________________ Use as directed.
Quantity: 1
Refills: ________
Epipen Jr. Other: ________________ Use as directed.
Quantity: 1
Refills: ________
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By
signing above, I hereby authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to
payors for the prescribed medication for this patient and to attach this Enrollment Form to the PA request as my signature.
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the
designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error
and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in
error, please notify the sender immediately by telephone and destroy all copies of this communication and any attachments.
Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers
not affiliated with CVS Specialty and/or one of its affiliates.
©2021 CVS Pharmacy, Inc. or one of its affiliates. 75-38688A 11/4/21 Page 3 of 3
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Asthma Enrollment Form Medications A-C

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document