Crohn's Disease 404-367-9199 Enrollment Phone: 404-367-9111 Deliver Medications To: Patient's Home Doctors Office Date Needed By: __________ Inj. Training/Admin. Y N Patient Demographics Prescription Insurance: (PLEASE ATTACH A COPY OF THE FRONT AND BACK OF THE PATIENT"S CARD)
Primary Prescription Insurance: RX BIN #: RX PCN#:
Patient ID/Policy Number: Patient RX Group Number:
Patient Clinical Information/History: (Please attach a copy of patient's recent chart notes, pathology, and labs)
Diagnosis: ICD-9 Code: Severity: Moderate SevereTB Test: Yes No Result: Date:
Does patient have active/serious infection: Yes NoPatient's weight: lbs or kg
Previous/Failed Medications: Date and Duration of Therapy: Reason for Discontinuation:
Patient Suport and Injection Training Authorization Patient Support and Injection Training
I authorize Encompass RX to enroll patient in the pharmaceutical company-assisted patient support program, corresponding with my prescribed therapy for purposes of receiving additional services such as, but not limited to, injection training. Patient further authorizes Encompass to release and communicate to the corresponding manufacturer the minimum necessary information about thier health condition and prescription(s) to: coordinate the delivery of products and services availablethrough the patient assistance program, aggregate de-identified data for market analysis, contact me occasionally for market research purposes, and provide educational information regarding therapies and disease states. I understand patient mayrevoke this authorization at anytime in writing by sending a letter to Encompass RX 500 Bishop St Ste A-3 Atlanta GA 30318. I understand that patient may refuse authorization and that refusal will not affect patient ability to obtain treatment fromthe pharmacy. Prescription Information Drug Strength Directions Qty Refill Starter Kit Induction Dose: Inject 400mg sc on day 1 and at week 2 and week 4.
Induction Dose: Inject 400mg sc on day 1 and at week 2 and week 4. 200mg PFS
Maintenance Dose: Inject 400mg sc every 4 weeks
200mg vial Maintenance Dose: Inject 400mg sc every 4 weeks
Other:__________________________________________________________
IBD Starter Pack
Induction Dose: Inject 160mg sc on day 1, 80mg on day 15, then maintenance dose
Induction Dose: Inject 160mg sc on day 1, 80mg on day 15, then
Ribavirin
Other:__________________________________________________________
600/600 Take 1 tablet po BID Inject 200mg sc on day 1, 100mg sc on day 15, then maintenance dose
100mg PFS Supportive Medications: 100mg AutoInjector Indcution Dose: IV at 5mg/kg (Each Dose=_____mg) on 0, 2,
Other:__________________________________________________________
Incivek 375mg Tablet Victrelis 200mg Capsule
Take 2 tablets (750mg) po TID 7 to 9 hours
INDUCTION DOSE: IV at 5mg/kg (Each Dose = _____mg) on weeks 0, 2, and 6
Remicade 100mg vial
MAINTENANCE DOSE: IV at 5mg/kg (Each Dose = _____mg) q 8 weeks
Other:__________________________________________________________
Prescriber Information: Prescriber Name: Office Phone: Office Fax: Office Contact: Physician Signature:
TÉRMINOS Y CONDICIONES GENERALES DE COMPRA 1. Aplicación. Los Términos y Condiciones Generales de El Comprador pagará las facturas que cumplan con i) todos los 12. Recursos, indemnización. Los derechos y recursos Compra (los “Términos”) que se describen a continuación serán requisitos legales aplicables, ii) los del Calendario de Pagos y iii) previstos en el Pedido en
TEA FORTÉ Company Fact Sheet Overview: Founded by acclaimed MOMA designer Peter Hewitt, Tea Forté electrified the specialty teaindustry with its introduction in 2003. With a mission to create the ultimate contemporary teaexperience, Tea Forté’s product line includes not only loose and bagged tea, but also servingand tea trays, café cups and tea sets. Beautifully packaged, Tea Forté
Crohn's Disease