PRESCRIPTION INTAKE FORM
Fax: 800-263-0251 • Phone: 800-541-4959 • Mon.- Fri. 8 a.m. to 7 p.m.
CONFIDENTIAL_HEALTH_INFORMATION:_Healthcare information is personal information related to a person’s healthcare. It is being faxed to you after appropriate authorization or under circumstances that don’t require authorization. You are obligated to maintain it in a safe, secure and confidential
manner. Re-disclosure of this information is prohibited unless permitted by law or appropriate customer/patient authorization is obtained. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state laws.
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Drug names are the property of their respective owners. Revised 7/22/2015
PATIENT’s Last Name First Name Gender DOB
Address City State ZIP Allergies Diagnosis Code & Mutation
Email Phone#: Home Phone#: Work/Mobile Parent/Guardian Name Phone#
( ) ( ) ( )
Primary Insurance Patient’s ID# Cardholder’s Name (if not patient) Provider Service Phone# Group#
( )
Secondary Insurance Patient’s ID# Cardholder’s Name (if not patient) Provider Service Phone# Group#
( )
Pharmacy Benefit RxBin# RxID# Rx Group# Pharmacist Help Desk Phone# Rx PCN#
( )
Please indicate desired dosage, directions, day supply or quantity, refills, and DAW.
CFTR MODULATOR
DOSAGE: Please specify mutation
DIRECTIONS
QUANTITY
REFILLS
DAW
(Y/N)
Kalydeco (ivacaftor)
150mg Mutation:__________
1 tablet every 12 hours OTHER:
Orkambi (lumacaftor/ivacaftor)
200mg/125mg Mutation:__________
2 tablets every 12 hours OTHER:
NEBULIZED MEDS
DOSAGE
DIRECTIONS
QUANTITY
REFILLS
DAW
(Y/N)
Bethkis (tobramycin)
300mg/4ml
BID Every Other Month OTHER:
Colistimethate powder
150mg *Sterile Water & Syringe below
BID Every Other Month OTHER:
* Sterile Water
5ml/vial *Reconstitute with _________ ml
BID Every Other Month OTHER:
* Syringe w/needle
3cc 5cc 10cc
BID Every Other Month OTHER:
TOBI (tobramycin)
300mg/5ml
BID Every Other Month OTHER:
TOBI (tobramycin) Podhaler
4 (28mg) capsules
BID Every Other Month OTHER:
Pulmozyme (dornase alfa)
2.5mg/2.5ml
QD OTHER:
Hyper-Sal 7% (sodium
chloride)
4ml
BID OTHER:
Pulmosal 7% (pH+) (sodium
chloride)
4ml
BID OTHER:
EQUIPMENT
QUANTITY
REFILLS
DAW
(Y/N)
eRapid Handset
eRapid Nebulizer System
Pari LC Plus
OTHER
DOSAGE
DIRECTIONS
QUANTITY
REFILLS
DAW
(Y/N)
Care Center/Physician’s Office Phone# Fax# DEA# NPI# Medicaid Provider#
Prescriber’s Name (PRINT) Date
Prescriber’s Signature (Substitution Permitted)
Prescriber’s Signature (Dispense As Written)
*** To promote quality, efficiency, and
accuracy, please submit prescriptions
to “Cystic Fibrosis Services-TX” via
your E-Prescribing software***
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