Medication
PRESCRIPTION INFORMATION
Pomalyst
®
Physician Authorization #
Diagnosis:
MMC90.00 Date
Pregnancy Category:
Thalomid
®
Physician Authorization # Diagnosis: MMC90.00 Date
Revlimid
®
Physician Authorization #
Diagnosis:
MDS D45.9 MMC90.00 Date
Weight kg / lbs BSAHeight cm / in m
2
Allergies
Prior Therapies
Concomitant Medications
Additional Comments
Current Cycle # Total # of Cycles
ICD-10 Description
Test Results: WNL:
SCr / CrCI Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
LFTs
Hgb / Hct
WBC
Electrolytes
CT / MRI / Other
Additional Information
Therapy:
New Reauthorization Restart
MEDICAL INFORMATION (Section must be completed to process prescription) (Attach separate sheet if needed)
Diagnosis — Please include diagnosis name with ICD-10 code
Adult Female – NOT of Reproductive Potential Adult Female – Reproductive Potential Adult Male
Female Child – NOT of Reproductive Potential Female Child – Reproductive Potential
Prior Authorization Reference number
Male Child
PATIENT INFORMATION Please complete the following or send patient demographic sheet
Address
Name
Alternate Phonehone
City, State, ZIP
Last Four of SS# Gender
Prescriber’s Name
Prescriber’s Name
Prescriber’s Name
Prescriber’s Name
Group / Hospital
NPI DEA
Address
City, State, ZIP
NPI Office Contact
NPI Office Contact
NPI
Office Contact
Contact Person Phone
Phone Fax
Patient
PRESCRIBER INFORMATION
DOB
Home P Language Preference:
English Spanish Other
Product Substitution permitted
Ship to: Patient Date Needs by Date
Dispense as Written
Office Other
* Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), and to sign any necessary forms on my
behalf as my authorized agent, including the receipt of any required prior authorization forms and the receipt and submission of patient lab values and other patient data. In the event that this pharmacy determines that it is unable to fulfill
this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.
Prescriber’s Signature Date: Supervising Physician Signature: Date:
Dose / Strength Directions Therapy Cycle Quantity
Revlimid
Pomalyst
Thalomid
CONFIDENTIALITY STATEMENT: This communication is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader
of this communication is not the intended recipient or the employee or agent responsible for delivery of the communication, you are hereby notified that any dissemination, distribution, or copying of the communication is strictly prohibited. If you have
received this communication in error, please notify us immediately by telephone. This form is not a valid prescription in Arizona.
08042161397
Oncology – Revlimid, Pomalyst,
Thalomid Enrollment Form
INSURANCE INFORMATION (Must fax a copy of patient’s insurance card including both sides)
Please detach before submitting to a pharmacy – tear here.
Electronic or digital signatures not accepted.
Specialty Pharmacy Enrollment Form
This form is not a valid prescription in Arizona
