The Lilly Cares
®
Foundation Patient Assistance Program (“Lilly Cares”) Diabetes Prescription FAX Form
Rx: I authorize Lilly Cares to act on my behalf for the purpose of transmitting this prescription to the appropriate pharmacy.
Signature _______________________________ ________________________________________
Dispense as written Substitution/brand exchange permitted
Your state may require that prescriptions follow certain content requirements or use a particular form. By signing below, you certify that you are abiding by laws applicable to
prescriptions and authorized prescribers in the states in which you are prescribing. I authorize Lilly Cares to act on my behalf for the limited purposes of transmitting this order
for prescription medication.
Patient Name: ____________________________________________________ Date of Birth: _____________Today’s Date: _____________
Address: _______________________________________________________________________________________________________________
City: ________________________________State: ___________ Zip Code: ___________ Phone: ____________________________________
Ship to Address (if different from patient address above, No P.O. Box or third-party vendor):
_______________________________________________________________________________________________________________________
City: ________________________________State: ___________ Zip Code: ___________
Drug Allergies: __________________________________________________________________________________________________________
Other Medications: ______________________________________________________________________________________________________
Baqsimi® (glucagon) nasal powder 3mg
BAQSIMI One Pack®
BAQSIMI Two Pack®
Basaglar® (insulin glargine injection)
U-100 KwikPen®
Glucagon Emergency Kit
(glucagon for injection)
1 mg Kit
Humalog® Mix 50/50™
(insulin lispro protamine
and insulin lispro injectable suspension)
U-100 vial U-100 KwikPen®
Humalog® Mix 75/25™ (insulin lispro protamine
and insulin lispro injectable suspension)
U-100 vial U-100 KwikPen®
Humulin® N (isophane insulin human suspension)
U-100 vial U-100 KwikPen®
Humulin® R U-500 (insulin human injection)
U-500 vial U-500 KwikPen®
Humulin® 70/30 (human insulin isophane suspension
and human insulin injection)
U-100 vial U-100 KwikPen®
Humulin® R (insulin human injection)
U-100 vial
Lyumjev™ (insulin lispro-aabc)
U-100 vial U-100 KwikPen®
U-200 KwikPen®
Trulicity® (dulaglutide) injection
0.75 mg/0.5 mL Pen
1.5 mg/0.5 mL Pen
3.0 mg/0.5 mL Pen
4.5 mg/0.5 mL Pen
Printed Prescriber Name and Title: _________________________________________________FAX: ____________________________________
State License Number and State:____________________________ NPI#: _________________Phone: __________________________________
Prescriber Office/Clinic Name and Shipping Address (No PO Box): __________________________________________________________________
____________________________________________________________________________________________________________________
Patients prescribed the Humulin R U-500 vial must be prescribed the BD™ U-500 insulin syringe to avoid medication errors. Do not use another type of syringe. The U-500
insulin syringe is not available through Lilly Cares. The safety and efficacy of Humulin R U-500 delivered by continuous subcutaneous insulin infusion/pump has not been
determined. Prescriber orders for Humulin R U-500 administered by continuous subcutaneous insulin infusion/pump will not be fulfilled.
IMPORTANT: This information is intended for the use of the person or entity to which it is addressed and may contain information that is confidential, the disclosure of which is
governed by applicable law. If the reader of this information is not the intended recipient, or the authorized agent or individual responsible to deliver it to the intended recipient,
you are hereby notified that any dissemination, distribution, or copying of this information is STRICTLY PROHIBITED. If you received this document in error, please notify us
immediately and destroy the related document.
Lilly Cares Foundation Patient Assistance Program
PO Box 13185 | La Jolla, CA 92039 | Phone: 1-800-545-6962 | Fax: 1-844-431-6650 | www.LillyCares.com
PP-AP-US-0452 09/2020 © Lilly USA, LLC 2020. All rights reserved. BAQSIMI®, Basaglar®, Humalog®, Humulin®, and KwikPen® are registered trademarks and Glucagon,
Humalog® Mix 75/25™, Humalog® Mix 50/50™, and Lyumjev™ are trademarks owned or licensed by Eli Lilly and Company, its subsidiaries or affiliates.
BD™ is a trademark of Becton, Dickinson and Company.
Humalog® (insulin lispro injection)
U-100 vial
U-100 KwikPen®
U-100 KwikPen® Junior
U-100 cartridge
U-200 KwikPen®
Quantity: ______________________________________
Refills: # ______________________________________
Sig:
__________________________________________
______________________________________________
Quantity: ______________________________________
Refills: # _______________________________________
Sig: __________________________________________
______________________________________________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Sig:
__________________________________________
______________________________________________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Max dose per day: __________ Refills: # ____________
Quantity (per month supply): 4 (max) 3 2 1
Refills: # ______________________________________
Sig:
__________________________________________
______________________________________________
Rubber stamps, signature by other office personnel for the prescriber, and computer-generated signatures will not be accepted.
Sig: __________________________________________
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Sig:
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Sig:
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Sig:
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Sig:
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click to sign
signature
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