Get Prescription Form

Referral/Prescription Form To ensure enrollment please fax to the Care Connection 1-800-847-3413 Telephone 1-800-847-3418 www. .com STEP 1 Complete Patient and Insurance Information Required please include copies of front and back of insurance cards First Name Last Name MI Prescription Drug Insurer/Pharmacy Benefit Manager City State ZIP Home Phone Work Phone Best Time to Contact BIN ID Address Cell Phone Clear Field Phone Group Primary Medical Insurance Cardholder Name Date of Birth Policy ID Number Email Primary Language if Not English Relationship to Cardholder Secondary Medical Insurance Known Allergies Patient does not have insurance Does patient have prescription drug card Yes No STEP 2 Read and Sign Patient Authorization Optional however signature is required for financial assistance By signing this Authorization I authorize my health plans physicians and pharmacy providers to disclose my personal health information including but not limited to information relating to my medical condition treatment care management and health insurance as well as all information provided on this form and any prescription Personal Health Information to Ther-Rx Corporation the Care Connection and its representatives agents and contractors collectively Ther-Rx for the following purposes 1 to establish my eligibility for benefits 2 to communicate with my healthcare providers and me about my medical care 3 to facilitate the provision of products supplies or services by a third party including but not limited to specialty pharmacies 4 to register me in any applicable product registration program required for my treatment and 5 to contact me with branded support materials related to my treatment. I understand that my Personal Health Information disclosed under this authorization may be redisclosed by Ther-Rx and is no longer protected by federal privacy laws. X Patient or Legal Guardian Signature Date STEP 3 Patient Eligibility Required Does the patient meet FDA-approved indication current pregnancy is singleton and patient has a history of singleton spontaneous preterm birth less than 37 weeks of gestation Please note that to be eligible for Care Connection services e.g. patient assistance programs and patient education materials the patient must meet the FDA-approved indication. Current Gestational Age If a patient does not meet the FDA-approved indication the prescription will be sent directly to a Specialty Pharmacy for appropriate processing. Insurance coverage of will be made at the determination of the individual s health plan. Weeks Days Date Recorded MM/DD/YY Currently on 17P Prescriber s Name Last First Specialty Medicaid Provider Practice Name Office Phone Rx hydroxyprogesterone caproate injection 250 mg/mL 5 mL multidose vial Dispense 1 vial followed by Sig Inject 1 mL IM each week NPI refills for a complete course of therapy Office Contact s Office Fax After-hours Phone Preferred Injection Setting Healthcare provider office Home via home health provider if approved by patient s insurer Direct Phone Please ship to Prescriber Patient Ancillary Supplies 18-g needle 3 mL syringe 21-g 1 1/2 needle Anticipated Start Date I certify that this therapy is medically necessary and that this information is accurate to the best of my knowledge. X Prescriber s Signature I authorize CDF Services LP CDF Services to be my designated agent and to act as my business associate as defined in 45 CFR 160. 103 to use and disclose any information about any of my patients enrolled with the Care Connection to the insurer of such patients and/or my patient and to obtain any information about such patients including any protected health information as defined in 45 CFR 160. I understand that I may refuse to sign this Authorization and that my treatment payment enrollment or eligibility for benefits is not conditioned on my signing this Authorization. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization at any time by mailing a letter requesting such cancellation to Ther-Rx Corporation 6900 Dallas Parkway Suite 200 Plano TX 75024 but that this cancellation will not apply to any information already used or disclosed through this Authorization. This Authorization expires five 5 years from the date signed below. X Patient or Legal Guardian Signature Date STEP 3 Patient Eligibility Required Does the patient meet FDA-approved indication current pregnancy is singleton and patient has a history of singleton spontaneous preterm birth less than 37 weeks of gestation Please note that to be eligible for Care Connection services e.g. patient assistance programs and patient education materials the patient must meet the FDA-approved indication. Current Gestational Age If a patient does not meet the FDA-approved indication the prescription will be sent directly to a Specialty Pharmacy for appropriate processing. Insurance coverage of will be made at the determination of the individual s health plan. Weeks Days Date Recorded MM/DD/YY Currently on 17P Prescriber s Name Last First Specialty Medicaid Provider Practice Name Office Phone Rx hydroxyprogesterone caproate injection 250 mg/mL 5 mL multidose vial Dispense 1 vial followed by Sig Inject 1 mL IM each week NPI refills for a complete course of therapy Office Contact s Office Fax After-hours Phone Preferred Injection Setting Healthcare provider office Home via home health provider if approved by patient s insurer Direct Phone Please ship to Prescriber Patient Ancillary Supplies 18-g needle 3 mL syringe 21-g 1 1/2 needle Anticipated Start Date I certify that this therapy is medically necessary and that this information is accurate to the best of my knowledge. X Prescriber s Signature I authorize CDF Services LP CDF Services to be my designated agent and to act as my business associate as defined in 45 CFR 160. .com STEP 1 Complete Patient and Insurance Information Required please include copies of front and back of insurance cards First Name Last Name MI Prescription Drug Insurer/Pharmacy Benefit Manager City State ZIP Home Phone Work Phone Best Time to Contact BIN ID Address Cell Phone Clear Field Phone Group Primary Medical Insurance Cardholder Name Date of Birth Policy ID Number Email Primary Language if Not English Relationship to Cardholder Secondary Medical Insurance Known Allergies Patient does not have insurance Does patient have prescription drug card Yes No STEP 2 Read and Sign Patient Authorization Optional however signature is required for financial assistance By signing this Authorization I authorize my health plans physicians and pharmacy providers to disclose my personal health information including but not limited to information relating to my medical condition treatment care management and health insurance as well as all information provided on this form and any prescription Personal Health Information to Ther-Rx Corporation the Care Connection and its representatives agents and contractors collectively Ther-Rx for the following purposes 1 to establish my eligibility for benefits 2 to communicate with my healthcare providers and me about my medical care 3 to facilitate the provision of products supplies or services by a third party including but not limited to specialty pharmacies 4 to register me in any applicable product registration program required for my treatment and 5 to contact me with branded support materials related to my treatment. I understand that my Personal Health Information disclosed under this authorization may be redisclosed by Ther-Rx and is no longer protected by federal privacy laws. I understand that I may refuse to sign this Authorization and that my treatment payment enrollment or eligibility for benefits is not conditioned on my signing this Authorization. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization at any time by mailing a letter requesting such cancellation to Ther-Rx Corporation 6900 Dallas Parkway Suite 200 Plano TX 75024 but that this cancellation will not apply to any information already used or disclosed through this Authorization. This Authorization expires five 5 years from the date signed below. I understand that my Personal Health Information disclosed under this authorization may be redisclosed by Ther-Rx and is no longer protected by federal privacy laws. I understand that I may refuse to sign this Authorization and that my treatment payment enrollment or eligibility for benefits is not conditioned on my signing this Authorization. I understand that I am entitled to a copy of this Authorization. I understand that I may cancel this Authorization at any time by mailing a letter requesting such cancellation to Ther-Rx Corporation 6900 Dallas Parkway Suite 200 Plano TX 75024 but that this cancellation will not apply to any information already used or disclosed through this Authorization. This Authorization expires five 5 years from the date signed below. X Patient or Legal Guardian Signature Date STEP 3 Patient Eligibility Required Does the patient meet FDA-approved indication current pregnancy is singleton and patient has a history of singleton spontaneous preterm birth less than 37 weeks of gestation Please note that to be eligible for Care Connection services e.g. patient assistance programs and patient education materials the patient must meet the FDA-approved indication. Current Gestational Age If a patient does not meet the FDA-approved indication the prescription will be sent directly to a Specialty Pharmacy for appropriate processing. Insurance coverage of will be made at the determination of the individual s health plan. Weeks Days Date Recorded MM/DD/YY Currently on 17P Prescriber s Name Last First Specialty Medicaid Provider Practice Name Office Phone Rx hydroxyprogesterone caproate injection 250 mg/mL 5 mL multidose vial Dispense 1 vial followed by Sig Inject 1 mL IM each week NPI refills for a complete course of therapy Office Contact s Office Fax After-hours Phone Preferred Injection Setting Healthcare provider office Home via home health provider if approved by patient s insurer Direct Phone Please ship to Prescriber Patient Ancillary Supplies 18-g needle 3 mL syringe 21-g 1 1/2 needle Anticipated Start Date I certify that this therapy is medically necessary and that this information is accurate to the best of my knowledge.