INSURANCE INFORMATION (please attach copy of your cards)

Patients Name:

Primary Insurance Co:

Secondary Insurance Co:

Phone:

Phone:

Policy#:

Policy#:

Group#:

Group#:

DOB:

City:

Height: Weight: Gender: Male Female

State: Zip:Address:

Home Phone: Cell Phone:

Email Address:

PHYSICIAN INFORMATIONPrescriber Name:

Prescriber Signature Date

Phone: Fax:

Email:Office Contact/Faxed by:

Deliver To: Office PatientNPI#:

Growth Hormone Referral Form

□E23.0 Hypopituitarism

□Q87.1 Prader-Willi Syndrome

□Q89.8 Other Specified Congenital Malformations

□18.9 Chronic Kidney Disease, Unspecified

□P05.10 Small Gestational

□Q87.89 Other Specified Congenital Malformation Syndromes, Not Elsewhere Classified

Primary Language: Allergies:

DIAGNOSIS INFORMATION

PATIENT INFORMATION

Prescriber Address:

To prevent generic substitution, Prescriber to handwrite “Brand Medically Necessary” and sign:

Your signature authorizes the pharmacy to act on your behalf to obtain prior authorization for the prescribed medications. This prescription is valid only if transmitted by facsimile machine by a licensed prescriber.

CLINICAL INFORMATIONInjection training needed: □ Yes □ No If yes, by whom: □ Prescriber office □ Other: ___________________

PRESCRIPTION INFORMATION (For IV medications attach a copy of your prescription)

□ GENOTROPIN® (somatropin)□ 5 mg cartridge□ 12 mg cartridge

□ GENOTROPIN MINIQUICK® (somatropin)

□ ___ mg MiniQuick®

□ HUMATROPE® (somatropin)□ 5 mg vial kit□ 6 mg cartridge kit□ 12 mg cartridge kit□ 24 mg cartridge kit

□ HUMATROPEN® Injection Device for Cartridge (somatropin)□ 6 mg□ 12 mg□ 24 mg

□ INCRELEX® (mecasermin)□ 40 mg/4 mL vial

□ NORDITROPIN FLEXPRO®(somatropin)□ 5 mg□ 10 mg□ 15 mg□ 30 mg

□ NUTROPIN AQ NUSPIN® (somatropin)□ 5 mg□ 10 mg□ 20 mg

□ SAIZEN® (somatropin)□ 5.8 mg vial kit□ 8.8 mg vial kit□ 8.8 mg Click.Easy□ 8.8 mg Saizenprep

□ SEROSTIM® (somatropin)□ 4 mg vial□ 5 mg vial□ 6 mg vial

□ ZOMACTON® (somatropin)□ 5 mg vial□ 10 mg vial

□ Q96.9 Turner Syndrome

□ R62.52 Idiopathic Short Stature (ISS)

□ Other Code: ______ Description: _________________

□ OMNITROPE® (somatropin)□ 5.8 mg/vial□ 5/1.5 mL cartridge□ 10/1.5 mL cartridge

□ Other:_______________________________

______________________________________

We’re focused and have a sense of urgency in providing our patients with valuable services such as copay assistance (when applicable),prior authorization support and expert medication/device counseling. We coordinate between the prescriber's office and the patient's insurance company

to provide quality, efficient and convenient service in our retail stores or home delivery from our Orlando facility.

Sig:________________________________________________________________________________________________________________________________________________

Qty: _____________________ Refills:____________________

Please confirm you have the current fax number of the intended recipient, and you have entered the fax number correctly before sending.

Walmart Specialty Pharmacy 1-877-453-4566 (Phone) 1-866-537-0877 (Fax)

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly Prohibited.

If you have received this message by error, please notify the sender immediately to arrange for return or destruction of these documents.