FIDELIS Enrollment Form
Inflectra
®
or Renflexis
®
Specific
Fax: 1-800-880-9022
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: ____________________________________________________ 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)
Primary Insurance
Name of Insurance: _______________________________
Member ID: _____________________________________
Prior Authorization: ________________________________
Prior Authorization Start Date: ________________________
Secondary Insurance
Name of Insurance: _______________________________
Member ID: _____________________________________
Prior Authorization End Date: _______________________
4 FIDELIS Authorization Information
Fidelis Contact Name: ______________________________
Phone: __________________________________________
Authorization Number: _______________________________
Authorization Start Date: ______________________________
Authorization End Date: _______________________________
5 DIAGNOSIS AND CLINICAL INFORMATION
Inflectra Infusion
Dosing: ________________________________________________
Frequency: _____________________________________________
Renflexis Infusion
Dosing: _____________________________________________
Frequency: ___________________________________________
Diagnosis, if available (attach any additional clinical information if available):
Code: ________ Description: ________________________ Code: ________ Description: ________________________
Patient new to therapy
Patient is transitioning to Coram
®
CVS Specialty
®
Infusion Services (Coram) and is not new to therapy
Date of last injection: ____________________
Date next injection due: __________________
Additional comments or instructions: _________________________________________________________________________________
6 MEDICATION DELIVERY AND NURSING MANAGEMENT
Please coordinate with patient to ship medication to their home and schedule nursing
Please coordinate with patient to ship medication to a Coram ambulatory infusion center (AIS)
Please coordinate with patient and physician to ship medication to the physician office and/or Clinic
Physician office contact: _________________ Physician office phone: ____________________
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 Coram.
75-48649B 040119
