Last name: ____________________________________________________________ First name: ____________________________________________________________
Address: ______________________________________________________________ City: __________________________________ State: _______ ZIP: ______________
Cell phone #: ________________________________Home phone #: __________________________________ Email: ___________________________________________
Gender: o Male o Female Date of birth: _______/_______/________ SSN (for insurance verification purposes only): _____________________________________
1. Patient Information
ICD-10 Code: o M17.0 o M17.11 o M17.12 o M17.2 o M17.31 o M17.32 o M17.4 o M17.5 o Other: __________________________________________
Select the appropriate injection-site location: o Left knee o Right knee o Bilateral
Clinical Information — Has the patient tried any of the following? (Please check all that apply):
o Immediate release intra-articular steroids (date of last injection: _____/_____/________) o NSAIDS o Analgesics o Physical therapy/exercise program
o Other (list all that apply): _____________________________________________________________________________________________________________________
o ZILRETTA (date of last injection: _____/_____/________) (select previous injection-site location): m Left knee m Right knee m Bilateral
Known drug allergies and notes: _________________________________________________________________________________________________________________
4. Diagnosis and Clinical Information
ZILRETTA
®
(triamcinolone acetonide extended-release injectable suspension), 32 mg (5 mL) Quantity: ___________
Directions for use: Administer ZILRETTA as a single intra-articular injection of triamcinolone acetonide, 32 mg (5 mL) for extended-release. ZILRETTA is supplied as a
single-dose kit containing a vial of 32 mg sterile triamcinolone acetonide (extended-release), 5 mL of sterile diluent, and a sterile vial adapter. Prepare using the diluent
supplied in the kit. Refer to the “Instructions for Use” provided with the kit for preparation and administration of ZILRETTA.
Additional directions:
_________________________________________________________________________________________________________________________
Dispense as written
Please attach a separate prescription if this section does not comply with your state’s prescription law. Prescriptions from New York must be issued electronically.
By signing below, I certify that (1) the above therapy is medically necessary and in the best interest of the patient listed above; (2) I authorize Flexion Therapeutics, Inc.
and its contractors and business partners (“Contractors”) to (i) supply any information to the insurer of the above named patient, (ii) forward the above prescription by
fax or other means of delivery to a licensed pharmacy, and (iii) verify benefits and coordinate the dispense of ZILRETTA where appropriate; and (3) I understand that
information I provide on this form, if signed by the patient, will be used by Flexion Therapeutics, Inc. and its Contractors as authorized by the patient.
Healthcare professional name (please print):
______________________________________________________________________________________________________
Healthcare professional signature: _____________________________________________________________________________________ Date: _____/_____/________
5. Prescription Information
6. Physician Authorization
Last name: _____________________________________________________________First name: ___________________________________________________________
NPI #: _____________________________State license #: ____________________________ Tax ID #: _________________________DEA #: _________________________
Office name: _________________________________________________________________________________________________________________________________
Address: ______________________________________________________________City: __________________________________ State: ________ZIP: ______________
Phone #: ______________________________________________________________Fax #: ________________________________________________________________
Primary Contact
Last name: __________________________________________First name: __________________________________Title: _______________________________________
Email: ______________________________________________Phone #: ____________________________________Fax #: ______________________________________
Preferred method of contact: o Phone o Email
2. Prescriber Information
Fax us the completed enrollment form
at 1-866-558-7939
Call us at 1-844-FLEXION (1-844-353-9466),
Monday - Friday, 8 am - 8 pm ET
Attach a copy of both sides of the patient’s insurance card(s) and/or fill out the insurance information below.
Is the patient enrolled in a government-funded healthcare program such as Medicare, Medicaid, VA, DoD, TRICARE, a qualified health plan (QHP), or a plan offered under a
state or federal exchange? o Yes o No
Primary Insurance
Plan name:
__________________________________________________________
ID #:____________________________ Group #: ____________________________
Plan phone #: ________________________________________________________
Policy holder: ________________________________________________________
Date of birth of policy holder (if different from patient): _______/_______/________
Relationship to patient: ________________________________________________
o Patient is uninsured
3. Insurance Information
Secondary Insurance
Plan name: __________________________________________________________
ID #:____________________________ Group #: ____________________________
Plan phone #: ________________________________________________________
Policy holder: ________________________________________________________
Date of birth of policy holder (if different from patient): _______/_______/________
Relationship to patient: ________________________________________________
o Benefits Investigation Only
o Specialty Pharmacy Triage
Services (please check all that apply)
o Full Benefits Support (benefits investigation,
prior authorization, and appeals support)
Page
1 of 2
FlexForward
®
Enrollment Form
Fax completed enrollment form to 1-866-558-7939
Patient name: ______________________________________________________________ Date of birth: _____/_____/________
In order to receive FlexForward services, you must complete this authorization to share protected health information.
Please note that you do not need to complete this authorization to start ZILRETTA. You may:
• Fax this completed form to FlexForward at 1-866-558-7939, or
• Call FlexForward at 1-844-FLEXION (1-844-353-9466) for instructions on other methods to complete this authorization
Some of the information that FlexForward needs to obtain from my healthcare provider(s) and health plan(s) about me, such
as my name, address, health insurance benefits, prescription drug coverage, and medical information, including medical
conditions and treatment and drug history, is protected health information. The collection, use, and disclosure of such
protected health information is protected under federal and some state privacy laws. In order for FlexForward to provide me
with the services described in the FlexForward services overview, the FlexForward staff may need to obtain from my healthcare
provider(s) and health plan(s) the protected health information about me described above. FlexForward may, in turn, share my
clinical experience with my healthcare provider. I have the right to revoke this authorization at any time. Revocation can be
completed by calling 1-844-FLEXION (1-844-353-9466). I understand that I do not have to enroll in the program, and that I can
still receive ZILRETTA as prescribed by my physician.
By signing the FlexForward Patient Authorization, I authorize my healthcare providers (such as my doctor and pharmacies
and pharmacists) and my health plan and/or health insurer to disclose protected health information about me to Flexion
Therapeutics, Inc., the manufacturer of ZILRETTA, and the companies working with it to provide the FlexForward services, so
that they may use this information as necessary to assist with:
(1) researching insurance coverage for ZILRETTA; (2) helping to arrange financial assistance to help me pay for my ZILRETTA
treatment by contacting my insurer, other potential funding sources, social workers, patient advocacy organizations, or patient
assistance programs on my behalf in order to determine if I am eligible for other financial assistance; (3) coordinating delivery
and administration of ZILRETTA to my designated treatment site(s); (4) collecting information related to ZILRETTA treatment to
assist in the coordination of my care and care of other osteoarthritis patients; (5) providing me with educational and support
services, materials and information related to ZILRETTA treatment to assist in the coordination of care; and (6) providing me with
information related to ZILRETTA and knee osteoarthritis or contacting me by mail, email, and/or telephone to ask me about my
experiences with, or thoughts about, products, services, and programs that FlexForward offers or sponsors, and to help
Flexion Therapeutics, Inc. develop new products, services and programs. I understand that the companies working with Flexion
Therapeutics, Inc. to provide FlexForward receive compensation for the services that they provide, including the service of
contacting me to discuss products and services.
Patient signature: ________________________________________________________________ Date: _____/_____/________
Patient phone #: _______________________________ Patient email: ________________________________________________
Authorized representative name: ________________________________ Relationship/Title: ______________________________
Authorized representative signature: _________________________________________________ Date: _____/_____/________
7. Patient Authorization
© 2019 Flexion Therapeutics, Inc. All rights reserved.
ZILRETTA and FLEXFORWARD are registered marks of Flexion Therapeutics, Inc.
October 2019. Z-00092v3
Fax us the completed enrollment form
at 1-866-558-7939
Call us at 1-844-FLEXION (1-844-353-9466),
Monday - Friday, 8 am - 8 pm ET
Page
2 of 2
FlexForward
®
Enrollment Form
Fax completed enrollment form to 1-866-558-7939
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome