PATIENT INFORMATION

PRESCRIBER INFORMATION

DIAGNOSIS/CLINICAL

INFORMATION

Patient Name: ___________________________ Birthdate: __________ Soc. Sec. #: ______________________ Preferred Phone: ___________ Address: __________________________________________________ Alternate Caregiver Name: ____________________________________

DEA#: ______________ NPI#: __________ Tax ID#: ______________Phone: ______________________ Fax: ________________________Key Contact: __________________ Phone: ______________________

Insurance Information: Please fax FRONT and BACK copy of ALL Insurance cards (Prescription and Medical)

Date Medication Needed:__________________ Ship To: m Patient’s Home m Prescriber’s Office m Pick-upInjection trainingby pharmacy? m

Dispense as written Date: Substitution Permissable Date_______________________________________________________________________________________________________________________

Dose/Strength Qty.

PHONE: 832-464-7616 • FAX: 713-669-1700TOLL FREE: 1-844-468-5600

www.primesourcerx.com

IMPORTANT NOTICE: This fax is intended to be delivered only to the named addressee and contains confidential information that may be protected health information under federal and state laws. If you are not the intended recipient, do not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. Pursuant to VA/OH/MO/VT law, only 1 medication is permitted per order form. Please use a new form for additional items. For additional forms, please contact your Account Manager or visit www.primesourcerx.com. If you need a medication not listed, please contact us.

By signing this form and utilizing our services, you are authorizing Primesource Rx and it’s employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies and patient assistance programs.

PRESCRIPTION INFORMATION

Medication

Provider Name: ____________________________________________ Address: __________________________________________________ City, State, Zip: _____________________________________________

Sex: m Male m Female Height: ______ Weight: _______ m lbs m kg.Known Allergies: ____________________________________________City: ___________________________State: _______ Zip: ___________Perferred Phone: _____________________________

Please FAX recent clinical notes, Labs, Tests, with the prescription

Prescriber, please sign and date below

Neurology Referral Form

o o o o o o

History: o o

o oIs the patient currently on therapy? No Yes Medication failed __________________________________________________ Will patient stop taking current therapy before starting new therapy? o oNo Yes How long will the patient wait before starting the new therapy? ________________________________________________________ Are there other medications patient currently taking? Please list: ________________________________________________________

Has the patient been previously treated for this condition? No Yes Medication failed ________________________________

Sig Refills

o

o

❑ Dose Titration:❑ Inject 0.25mg (1mL) subcutaneously every other day

Weeks 1–2: Inject 0.0625 mg/0.25 mL subcutaneously every other dayWeeks 3–4: Inject 0.125 mg/0.50 mL subcutaneously every other dayWeeks 5–6: Inject 0.1875 mg/0.75 mL subcutaneously every other dayWeeks 7+: Inject 0.25 mg/1 mL subcutaneously every other day

Betaseron 0.3 mg vial (14 vials / kit)

❑ Inject 20 mg subcutaneously daily ❑ 20 mg preflled syringe (PFS) (30 syr/ kit) o Copaxone

o Extavia 0.3 mg vial 15 oDose Titration:

o o

o o Gilenya o 0.5 mg (30 pills/ month)

o Avonex

Inject 0.25 mg (1 mL) subcutaneously every other day

Weeks 1–2: Inject 0.0625 mg/0.25 mL subcutaneously every other dayWeeks 3–4: Inject 0.125 mg/0.50 mL subcutaneously every other dayWeeks 5–6: Inject 0.1875 mg/0.75 mL subcutaneously every other dayWeeks 7+: Inject 0.25 mg/ 1 mL subcutaneously every other day

❑ 20 mg preflled syringe (PFS) (30 syr/ kit) ❑ Inject 20 mg subcutaneously daily

o Rebif

oooo

oo

Weeks 1–2: Inject 8.8 mcg subcutaneously three time a week, Weeks 3–4: Inject 22 mcg subcutaneously three times a week, Weeks 5+: Inject 44 mcg subcutaneously three times a weekInject 44 mcg subcutaneously three times a week.

o

o

4-week supply(1 kit)

4-week supply

Relapsing Remitting Primary Progressive Secondary Progressive Progressive Relapsing

Revised 11/16/2016

Other (ICD10 Code and description) _________________________________________________________________Diagnosis: G35 Multiple Sclerosis

Rep Code

❑ 30 mcg prefilled syringe (PFS) (4 dose / kit)❑ 30 mcg lyophyllized vial (4 dose / kit)❑ 30 mcg Avonex Pen (4 dose / kit)

❑ Inject 30 mcg intramuscularly once a weekWeek 1: Inject 7.5 mcg intramuscularly weeklyWeek 2: Inject 15 mcg intramuscularly weeklyWeek 3: Inject 22.5 mcg intramuscularly weeklyWeek 4+: Inject 30 mcg intramuscularly weekly

❑ Dose Titration:

1 kit

❑ 40 mg prefilled syringe (PFS) (12 syr/ kit) ❑ Inject 40 mg subcutaneously three times a week 1 kit

o Glatopa (generic Copaxone)

1 kit

1 kit

30 capsTake one 0.5 mg capsule by mouth once daily

Titration Pack (six 8.8 mcg and six 22 mcg PFS)22 mcg PFS44 mcg PFSTitration Pack Rebidose® (six 8.8 mcg prefilled autoinjectors and six 22 mcg prefilled autoinjectors)Rebidose® 22 mcg prefilled autoinjector Rebidose® 44 mcg prefilled autoinjector

4-week supply(1 kit)

300 mg/10ml vial o o o Ocrevus infuse 300 mg IV on day 1, followed by 300 mg IV infusion 2 weeks later Infuse 600 mg IV administered once every 6 months (beginning 6 months after

the first 300 mg dose).

oo Tysabri oo

o 1 month supply Infuse 300mg IV every 4 weeks (after registering patient with TOUCH)

Pre-medication protocol: Tylenol 1000mg PO and Benadryl 25mg PO Date of last interferon dose ____________________