Crohn’s/UC Metro Drugs Pharmacy 134-02 Jamaica Avenue Enrollment Form Queens, NY 11418 Phone : 718-206-4653 Fax Referrals To: (718) 795-1639 PATIENT INFORMATION Patient Name: ___________________________________________________________________________________________________ Date of Birth: ____ /____ / ____ Male Female ( Childbearing) SSN: ____ -____ - ____ Address: _____________________________________________ City: _______________________ State: ________ Zip: __________ Phone: ( ____ ) - ____ - ________ Alternate Phone: ( ____ ) - ____ - ________ email: _________________________________________ Preferred method of contact: Phone Email Text Other: __________________ Height: ________ in Weight: ________ lb Allergies: ____________________________ Current Medications: _____________________________________________________________________________________________ PRESCRIPTION BENEFITS PROVIDER PRESCRIBER INFORMATION Provider: ________________________________ Prescriber Name: _______________________________________________________ Phone: ( ____ ) - ____ - _____ Office Phone: _____________________ Fax: ________________________________ ID #: __________________ Group #: __________ Clinic/Hospital Affiliation: _________________________________________________ Rx BIN: ___________ Rx PCN: _______________ Address ________________________City:______________State:____ Zip:________ (Please fax copy of front and back of card) License#:________________NPI#:__________________Contact:_________________ CLINICAL CONSIDERATIONS Crohn’s Severity: Moderate Severe Is patient at risk for Hepatitis B infection? Yes No Enterocutaneous/Recto Vaginal Fistulas Yes No If Yes, has Hepatitis B been ruled out or treatment initiated? Yes No Has Patient been diagnosed with Heart Failure? Yes No Does patient have a Latex allergy? Yes No Has patient been diagnosed with Lymphoma? Yes No Patient weight:________________ kg/lbs Does patient have serious/active infection? Yes No Are there any contradications to previous treatments? Yes No Has TB test been performed? Yes No If Yes, Results: _____________________ DIAGNOSIS Crohn’s Disease: K50.00 K50.10 K50.80 K50.90 K50._______ Ulcerative Colitis: K51.90 K51._____ Other: _________________ Other: ______________________ Medication Strength / Directions for use Quantity Refills Cimzia Starter Kit Induction Dose: Inject SC 400mg (2 Injections) on day 1, and at weeks 2 and 4. 1 kit (6 CIMZIA ® 200mg/1mL Prefilled prefilled Maintenance Dose: Inject subcutaneously 400mg (2 injections) every 4 weeks. syringes) Syringe 200mg vial 300mg in a single dose Recommended dosage in UC and CD: 300mg infused IV over 30 ENTYVIO ® vial in individual carton minutes at 0.2 and 6 weeks, then every 8 weeks thereafter. Induction Dose: Inject subcutaneously 160mg (4 pens) on day 1, then Crohn’s Starter Package 80mg (2 pens) on day 15, then maintenance dosing. HUMIRA ® 40mg Self Injectable Pen 1 Package Maintenance Dose: Inject SC 40mg (one pen) every other week. 40mg Prefilled Syringe Maintenance Dose: Inject SC 40mg (one syringe) every other week. Induction Dose: IV at 5mg/kg (Dose = ___________ mg) at 0.2, and 6 weeks _______ # 100mg vial of 100mg REMICADE ® Maintenance Dose: IV at 5mg/kg (Dose = ___________ mg) every 8 weeks _____________ mg/kg vials Other: ________________________________________________________ 100mg/0.5mL SmartJect Autoinjector Inject 100mg (0.5ml) SIMPONI ® 100mg/0.5mL Prefilled Syringe subcutaneously once a month 2mg/kg IV at weeks 0 and 4, then every 8 weeks SIMPONI ARIA® Other: _______________________________________________________________ 130mg/26mL IV vial Induction Dose: Infuse 260mg Infuse 390mg Infuse 520mg STELARA ® 90mg Prefilled Syringe Maintenance Dose: Inject 90mg every 8 weeks subcutaneously By signing below, I authorize Metro Drugs Pharmacy, LLC and its representatives to act as an agent to initiate and execute the insurance prior authorization process. I also certify that the above therapy is medically necessary and that the information above is accurate to the best of my knowledge. Prescriber’s signature: _________________________________ MD DO PA CRNP Date: ____ /____ / ____ NO STAMPS In order for a brand name product to be dispensed, the prescriber must handwrite “Brand Necessary” or “Brand Medically Necessary on the prescription. SHIPPING INFORMATION Ship to: Patient Physician/Clinic Date Shipment Needed By: ____ /____ / ____ CONFIDENTIALITY NOTICE: This fax is for use only by the person named above. It is private. It may be subject to HIPAA Privacy and security rules. You may not use, copy or share this fax without permission. Please call us at (877) 577-1447 if you received this fax by mistake. Do not destroy this fax until you have spoken with us. We may ask you to destroy or return the fax to us. Thank you for your cooperation. Metro Drugs LLC.