Dolphin’s Gastroenterology Checklist

© 2020. Dolphin Health Specialty Pharmacy. All rights reserved.

Please make sure you send all of the following in one fax if possible. This will help expedite our eligibility and prior authorization process.

What is attached?

❑ Demographics

❑ Last 2 Visit Notes

q TB Test Results (i.e. Quantiferon Gold or PPD, *** only if RX for Biologics)

❑ Evidence of diagnosis (i.e. colonoscopy, and/or pathology reports)

❑ Current medications

Special Comments or Requests

www.dolphinhealth.com

Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605

Page 1 of 3

PLEASE ATTACH FRONT AND BACK OF THE PATIENT’S INSURANCE CARD

FRONT

BACK

Sender

ATTN:

Gastroenterology Form

© 2020. Dolphin Health Specialty Pharmacy. All rights reserved Updated 4/23/2020. Page 2 of 3

www.dolphinhealth.com

Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605

Clinical Info

Diagnosis Diagnosis Date: Negative TB Test Date:

q K50.0 Crohn’s Disease – Small Intestine q K51.0 Ulcerative Colitis

q K50.1 Crohn’s Disease – Large Intestine q K51.2 Ulcerative Procolitis

q K50.8 Chron’s Disease – Both Intestines q K51.3 Ulcerative Rectosigmoiditis

q K50.9 Crohn’s Disease – Unspecified q K51.5 Left Side Colitis

q K51.8 Ulcerative Colitis - Unspecified q Other:

Concurrent Medications: Allergies:

1

Provider Info

Name Contact

NPI DEA LIC

Address City State, Zip

Phone Extension Fax

CoordinationToday Need By RX Type ❑ New ❑ Refill

Ship To ❑ All fills to Patient ❑ 1st fill to Clinic ❑ All fills to Clinic q Other Training By ❑ Dolphin ❑ Clinic ❑ N/a

Insurance ❑ Commercial ❑ Medicare ❑ Medicaid ❑ Cash Patient Impaired ❑ Hearing ❑ Vision

Patient Info

Name DOB SSN

Address City State, Zip

Phone Caretaker Language

Email Height ❑ In ❑ cm Weight ❑ lb ❑ kg

Tried & Failed

Medication Start Date End Date Reason for Discontinuation

Non-Adherence Concerns?

Gastroenterology Form

© 2020. Dolphin Health Specialty Pharmacy. All rights reserved Updated 4/23/2020.

www.dolphinhealth.com

Page 3 of 3

Signature

By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to Dolphin Health to act as the prescriber’s agent to begin and to execute the prior authorization process and to help the patient apply to co-pay assistance programs, including all foundations and manufacturer programs if necessary.

Provider Date q Do Not Substitute

Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605

PRESCRIPTION

Medication Strength Directions QTY (months) Refills

❑ Cimzia ®❑ Starter Kit❑ 200mg/mL Pre-filled Syringe

❑ Induction: Inject 400mg SQ on days 0, 14, and 28.❑ Maintenance: Inject 400mg SQ every 28 days.

❑ 6❑ 12

❑ Humira ®

❑ Starter Kit ❑ Pens ❑ Syringes❑ Induction: Inject 160mg SQ day 1, then 80mg SQ on day 15.❑ Maintenance: Inject 40mg SQ every other week.

❑ 6❑ 12❑ 40mg/0.8mL Pen

❑ 40mg/0.8mL Pre-filled Syringe

❑ Humira ®(citrate free)

❑ Starter Kit ❑ Pens ❑ Syringes

❑ Induction: Inject 160mg SQ day 1, then 80mg SQ on day 15.❑ Maintenance: Inject 40mg SQ every other week.

❑ 6❑ 12

❑ 40mg/0.4mL Pen

❑ 40mg/0.4mL Pre-filled Syringe

❑ Simponi ®❑ 100mg/mL SmartJect® Autoinjector❑ 100mg/mL Pre-filled Syringe

❑ Induction: Inject 200mg SQ at week 0, then 100mg SQ at weeks 2 and 6.

❑ Maintenance: Inject 100mg SQ every 4 weeks.

❑ 6❑ 12

❑ Stelara ® ❑ 90mg/mL Pre-filled Syringe❑ Induction: Clinic to coordinate. Date of IV Induction Dose.

Date of Induction: ___________________________

❑ Maintenance: Inject 90mg SQ every 8 weeks, starting 8 weeks after IV Induction.

❑ 6❑ 12

❑ Xeljanz ®❑ Induction: q 10mg ❑ Induction: Take 10mg by mouth TWICE daily for _____ weeks.

❑ Maintenance: Take 5mg by mouth TWICE daily.❑ Maintenance: Take 10mg by mouth TWICE daily.

❑ 6❑ 12❑ Maintenance: q 5mg q 10mg

❑ Xeljanz XR ®

❑ Induction: ❑ Induction: Take 22mg PO ONCE daily.

❑ Maintenance: Take 11mg PO ONCE daily.

❑ Maintenance: Take 22mg PO ONCE daily.

❑ 6❑ 12❑ Maintenance:

q 11mg

q 11mg q 22mg

Verify

Patient DOB Provider Date

Gastroenterology Form