Fillable Specialty Pharmacy Request Form

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Specialty Pharmacy Request Form

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Specialty Pharmacy Request Form
Paragard
®
is a registered trademark, and Paragard Specialty Pharmacy
SM
is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc. C-US-PAR-000041 October 2020
If patient is a minor and is signing the authorization on the following page on her own behalf, please arm that:
This patient has the capacity to consent to treatment with Paragard under the law of the state in which I practice (and the consent of a parent or guardian is not required), or
This patient’s parent or guardian has consented to the patient’s treatment with Paragard, as required by applicable state law.
Patient Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Date of Birth:
See Attached Demographic Sheet
Prescriber Name:
State Lic #:
NPI #: Specialty:
Facility Name:
Address:
City: State: Zip:
Ship To Address (Required):
City: State: Zip:
Prescriber’s Phone:
Prescriber’s Fax:
PREFERRED COMMUNICATION
Oce Contact Name:
Direct Phone Number:
Direct Email Address:
Direct Fax:
PATIENT INFORMATION PRESCRIBER INFORMATION
Primary
Insurance:
City: State:
Plan #:
Group #:
Phone #:
Subscriber Name (First/Last):
ID #:
Employer:
Secondary
Insurance:
City: State:
Plan #:
Group #:
Phone #:
Subscriber Name (First/Last):
ID #:
Employer:
Rx Card
(PRM):
PBM BIN:
City: State:
Group #:
Phone #:
Subscriber Name (First/Last):
ID #:
Employer:
INSURANCE INFORMATION (Please attach copies of front & back of cards) N/A (Patient Self-Pay)
PAR T380A – QTY 1/Paragard (intrauterine copper
contraceptive) to be inserted one time by prescriber.
PRESCRIPTION INFORMATION
Z30.430: Encounter for insertion of
intrauterine contraceptive device
Other: Please Specify
DIAGNOSTIC INFORMATION (ICD-10 Code)
Patient Signature: Date: / /
Prescriber Signature: Date: / /
For ARNP, NP, and PA, collaborative physician agreement is with: Date: / /
IMPORTANT: Prescriber gives the selected specialty pharmacy express permission to use his/her NPI number included herein for the purpose of identifying the referring prescriber to the authorized pharmacy benefits
manager and/or payer. The selected specialty pharmacy accepts no liability regarding any decisions concerning claims, coverage or payment, which are made in the sole discretion of the health plan administrators and insurers.
The selected specialty pharmacy makes no assurance that any prescribed drug will be covered or reimbursed at any specific level under any patient’s insurance plan, or that any specific pharmacy will provide the prescribed drug.
Page 1
Specialty Pharmacy
SPECIALTY PHARMACY (Choose one)
Biologics by McKesson
City Drugs – A BioMatrix Specialty Pharmacy
Fax
1-855-215-5315
1-212-988-4501
Phone
1-888-275-8596
1-855-988-4500
Hours of Operation
Mon-Fri 9:00 AM - 6:00 PM ET
Mon-Fri 9:00 AM - 7:00 PM ET
Sat 9:00 AM - 3:00 PM ET
Complete the form, then fax pages 1 and 2 to your chosen specialty pharmacy. Give page 3 to the patient.
WEB: ParagardAccessCenter.com
PHONE: 1-877-PARAGARD
I understand that my signature will be used as an approval allowing the Specialty Pharmacy to dispense Paragard. If I have a financial responsibility for obtaining Paragard,
I understand that the selected specialty pharmacy will contact me prior to the dispense.
Patient Authorization for Specialty Pharmacy
In accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations and rules
“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my health and personal
information to CooperSurgical, Inc. and it’s specialty pharmacy agents (and their aliates, respective representatives, and
agents) in furtherance of the below-stated authorized purposes.
Authorized Purposes
I understand that the selected specialty pharmacy will receive my health and personal information, which may include my
name, address, patient insurance identification number, date of birth and other information necessary to obtain health insurance
benefit verification for the following purposes: (1) the administration of CooperSurgical’s Paragard Program; (2) to conduct benefit
verification determining insurance reimbursement and coverage of Paragard; (3) to contact me to discuss any relevant co-pay;
(4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare provider; (7) to contact me by
telephone in furtherance of conducting benefits verifications investigations and/or specialty pharmacy dispense; and (8) if I
choose to self-pay for Paragard, to invoice me and to otherwise contact me to collect payment for the Paragard unit.
By signing the following form, I understand:
1. Once my healthcare provider gives the selected specialty pharmacy information about me based on this Authorization, my
medical and health information may be subject to redisclosure and is no longer protected by federal privacy regulations.
I further understand and agree that the selected specialty pharmacy may retain my medical and health information as
disclosed under this Authorization after this Authorization expires.
I also understand that in the event of an audit, and for purposes of such an audit, some information may also be disclosed to
CooperSurgical, Inc., the manufacturer of Paragard, or its aliates after this Authorization has expired, so long as the audit is
for a period of time when this Authorization was in eect.
2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not aect my ability to
obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance benefits.
3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider, health plan and/or
pharmacy that refers to (or with a copy of) this Authorization form, or to the selected specialty pharmacy. I understand that if
I revoke this Authorization, it will not aect prior disclosures made to the selected specialty pharmacy and any use of such
information by the selected specialty pharmacy in reliance of this Authorization. I understand that I have the right to receive
a copy of this Authorization.
4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.
Signature of Patient or Legal Personal Representative: Date: / /
Name of Patient or Legal Personal Representative:
(If Applicable) Description of Personal Representative’s Authority to Sign for Patient:
Please see Important Safety Information and
Full Prescribing Information for Paragard at Paragard.com.
Page 2
WEB: ParagardAccessCenter.com
PHONE: 1-877-PARAGARD
Paragard
®
is a registered trademark, and Paragard Specialty Pharmacy
SM
is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc. C-US-PAR-000041 October 2020
Please see Important Safety Information and
Full Prescribing Information for Paragard at Paragard.com.
Page 3
WEB: ParagardAccessCenter.com
PHONE: 1-877-PARAGARD
Paragard
®
is a registered trademark, and Paragard Specialty Pharmacy
SM
is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc. C-US-PAR-000041 October 2020
Dear Patient,
Your healthcare provider has ordered Paragard through the following specialty pharmacy.
This specialty pharmacy may contact you regarding Paragard, or you may contact them directly
if you have any questions.
Specialty Pharmacy Phone Number
Biologics by McKesson 1-888-275-8596
City Drugs – A BioMatrix Specialty Pharmacy 1-855-988-4500
To learn more visit Paragard.com
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Specialty Pharmacy Request Form

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Completed 30 April 2021

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