Crohn's Disease
Phone: 404-367-9111
Deliver Medications To:
Patient's Home
Doctors Office Date Needed By: __________ Inj. Training/Admin. Y N
Patient Demographics
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:

Source: http://encompassrx.com/wp-content/uploads/2013/07/ibd.pdf


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