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Prescriber Signature Date IF YOU WOULD PREFER TO CALL THIS INFORMATION INTO THE FLRx PHARMACY HELP DESK 1-800-724-5033 10/06. Patient Name Please Print FLRx Patient ID number MD Name MD Phone MD DEA Patient Birthdate MD Specialty MD FAX QUESTIONS / INDICATIONS FOR MEDICAL NECESSITY YES NO 1. In Irritable Bowel Syndrome or chronic idiopathic constipation Drug Prior Authorization FAX Form Please complete information sign and date and FAX to the FLRx Pharmacy Help Desk Fax Number 800-956-2397 Please allow 3 business days for review of this request. What is this patient s diagnosis Constipation predominant irritable bowel syndrome see question 2 2. Has the patient met the diagnostic criteria for IBS Check all below that apply At least 12 weeks of continuous or recurrent symptoms in the preceding 12 months of A. Abdominal pain or discomfort which is Relieved with defecation and/or Onset associated with a change in frequency of stool and/or AND B. Symptoms that Cumulatively Support the Diagnosis of IBS Two or more of the following symptoms at least a quarter of occasions or days Abnormal stool frequency less than 3 bowel movements per week Passage of mucus Bloating or feeling of abdominal distension Rome II Symptom Criteria for IBS -1998 3. Does the patient present with the following Check all below that apply Less than 3 spontaneous bowel movements per week Straining hard stools or incomplete evacuation at least 25 of defecations Both of the above for at least 6 months The constipation is idiopathic in nature i*e* not drug induced At least one month of lifestyle changes including diet and exercise 4. Please list other therapies tried Fiber PEG-3350 Stool softeners Other Note The efficacy of for long term treatment has not been established* I certify that information given/provided on this form is accurate as of this date. What is this patient s diagnosis Constipation predominant irritable bowel syndrome see question 2 2. Has the patient met the diagnostic criteria for IBS Check all below that apply At least 12 weeks of continuous or recurrent symptoms in the preceding 12 months of A. Has the patient met the diagnostic criteria for IBS Check all below that apply At least 12 weeks of continuous or recurrent symptoms in the preceding 12 months of A. Abdominal pain or discomfort which is Relieved with defecation and/or Onset associated with a change in frequency of stool and/or AND B. Abdominal pain or discomfort which is Relieved with defecation and/or Onset associated with a change in frequency of stool and/or AND B. Symptoms that Cumulatively Support the Diagnosis of IBS Two or more of the following symptoms at least a quarter of occasions or days Abnormal stool frequency less than 3 bowel movements per week Passage of mucus Bloating or feeling of abdominal distension Rome II Symptom Criteria for IBS -1998 3. Symptoms that Cumulatively Support the Diagnosis of IBS Two or more of the following symptoms at least a quarter of occasions or days Abnormal stool frequency less than 3 bowel movements per week Passage of mucus Bloating or feeling of abdominal distension Rome II Symptom Criteria for IBS -1998 3. Does the patient present with the following Check all below that apply Less than 3 spontaneous bowel movements per week Straining hard stools or incomplete evacuation at least 25 of defecations Both of the above for at least 6 months The constipation is idiopathic in nature i*e* not drug induced At least one month of lifestyle changes including diet and exercise 4.

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