Phone: 866.892.1580• Fax: 866.892.2363
Date Shipment Needed: Ship To: Patient Prescriber
Nursing needed; Training needed ►All the supplies including syringes and needles will be dispensed if needed.
ORAL ONCOLOGY REFERRAL FORM
______________________________________
PATIENT INFORMATION
Patient Name:
DOB:
Sex:
M
F
Weight:
lbs.
kg.
SSN:
Phone:
Allergies:
Address:
City:
State:
Zip:
Emergency Contact:
Phone:
Please attach demographic information
PRESCRIBER INFORMATION
Prescriber:
NPI:
DEA:
State Lic:
Supervising Physician:
Practice Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Key Office Contact:
Phone:
DIAGNOSIS INFORMATION / MEDICAL ASSESMENT
Primary Diagnosis:
C17.9 Gastrointestinal Stromal Tumors
C18.3 - C19 Metastatic Colorectal Cancer
C22.0 - C22.2 - C22.7 - C22.8 Hepatocellular Carcinoma
C25.9 Adenocarcinoma of Pancreas C34.90 Pulmonary Malignancy C50.019 Breast Cancer C64.9 Renal Cell Carcinoma 191.9 Glioblastoma
C73 Malignant Neoplasm of Thyroid Gland C82.90 - C82.99 Cutaneous T-Cell Lymphoma (Mycosis Fungoides or Sezary’s Disease)
C90.00 - C90.01 - C90.02 Multiple Myeloma C92.10 - C92.11 - C92.12 Chronic Myeloid Leukemia L52 Erythema Nodosum (ENL) Other: __________________
Has patient been treated previously for this condition? Yes No Medication(s): __________________________________________________________________
Cancer Stage: Stage 0 Stage I Stage II Stage III Stage IV Other ____________________________________________________________________________________
Is patient currently on therapy? Yes No Medication(s): ____________________________________________________________________________________
Will patient stop taking the above medication(s) before starting the new medication? Yes No If yes: _________________________________________________
How long should patient wait before starting the new medication? ________________________________________________________________________________
Other medications patient is currently taking including OTC medications with dosage and direction (or fax medication profile):
_____________________________________________________________________________________________________________________________________
INSURANCE INFORMATION
Please attach front and back of patient’s insurance card (medical and prescription)
COPAY CARD ENROLLMENT
Please check if enrolling in copay card
Copay ID:
PRESCRIPTION INFORMATION
Medication
mg
QTY.
SIG.
Refills
Afinitor
Bosulif
Capecitabine
Erivedge
Erleada
Gleevec
Hycamtin
Inlyta
Kisqali
Mekinist
Nerlynx
Nexavar
Nubeqa
Odomzo
Rydapt
Sprycel
Stivarga
Sutent
Tafinlar
Tarceva
Tasigna
Temodar
Temozolomide
Topotecan
Tykerb
Votrient
Xalkori
Xtandi
Zytiga
Other:
__________________________________________________________
Dosage:
____________________________________________
QTY:
Refills:
Antimetics:
Chemo-induced N/V
Radiation-induced N/V
Aloxi
Akynzeo
Dolasetron
Emend
Granisetron
Prochlorperazine
Ondansetron
Other:
__________________________
Dosage:
__________________________________________________________________________________________________________
QTY:
Refills:
Supportive Agents:
Neupogen
Neulasta
Procrit
Epogen
Aranesp
Prothelial
Loperamide
Other:
___________________________________
Dosage:
__________________________________________________________________________________________________________
QTY:
Refills:
Prescriber’s Signature:
DAW (Dispense as Written) Date: _____________
Prescriber certifies that this referral form contains an original signature and is signed by the treating prescriber. NO STAMPED SIGNATURES WILL BE ACCEPTED. Where required by law, send prescription on official state
prescription blank. In the event requested agent is not available through AcariaHealth, this prescription shall be forwarded to an eligible pharmacy.
IMPORTANT NOTICE: This message may contain privileged and confidential information and is intended only for the individual named. If you are not the named addressee, you should not disseminate, distribute or copy this fax. Please notify the sender
immediately if you have received this document by mistake, then destroy this document. Please direct all verification or notification to AcariaHealth or any of its subsidiaries using the contact information provided on this coversheet.
9.10.19
Page 1 of 1
click to sign
signature
click to edit
![]()
