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Dispense as written Date of signature 2016 Smith Nephew Inc. is a registered trademark of Smith Nephew Inc DIRECT is a servicemark of Smith Nephew. Fax demographic sheet or patient s pharmacy benefits card along with enrollment form. Email1 NPI Name Pharmacy help desk Policyholder name Relationship to patient Member ID Group ID Rx BIN PCN Tax ID Fax Address City State Zip Office contact name Home health agency name if applicable Patient diagnosis Patient information Diagnosis code Patient name first last Please list any known allergies to medication or other substances Date of Birth Gender M F Treatments failed dosage dates of therapy and reason for failure Home phone Alternate phone Wound care plan SSN Last 4 digits Wound location Ship to NKDA Patient MD Office Emergency contact Other Phone Patient s local pharmacy name Width Location 1 Length cm mm in Provider attestation Prescription information Drug Ointment 250 units/g Quantity sufficient 30 days supply Date Sig Directions Apply a nickel thick layer to the affected area s once daily as directed Refills By signing below I verify that the information being disclosed in this enrollment form is complete and accurate to the best of my knowledge. I understand that ASPN Pharmacies LLC ASPN reserves the right at any time and for any reason without notice to modify this enrollment form or to modify or discontinue any services or assistance provided through this Program. Finally I authorize ASPN as my designated agent to use and disclose my patient s protected health information as may be necessary for treatment payment and healthcare operations including to verify the accuracy of any information provided to verify patient eligibility to provide for payment and reimbursement and to forward the above prescription information by fax or other mode of delivery to a pharmacy for fulfillment. Please send me status updates via email. You may opt-in to receive emails from ASPN regarding the status of your patient s prescription. By agreeing to receive emails from ASPN you acknowledge that ASPN will send standard emails to you via the Internet. Enrollment form Customer service 844 276-4273 and press 2 Fax completed form to 888 365-2035 Indicates required field Prescriber information Patient insurance information/Pharmacy benefit plan Prescriber name Fill in fields with pharmacy benefits NOT medical. OR.. Fax demographic sheet or patient s pharmacy benefits card along with enrollment form. Email1 NPI Name Pharmacy help desk Policyholder name Relationship to patient Member ID Group ID Rx BIN PCN Tax ID Fax Address City State Zip Office contact name Home health agency name if applicable Patient diagnosis Patient information Diagnosis code Patient name first last Please list any known allergies to medication or other substances Date of Birth Gender M F Treatments failed dosage dates of therapy and reason for failure Home phone Alternate phone Wound care plan SSN Last 4 digits Wound location Ship to NKDA Patient MD Office Emergency contact Other Phone Patient s local pharmacy name Width Location 1 Length cm mm in Provider attestation Prescription information Drug Ointment 250 units/g Quantity sufficient 30 days supply Date Sig Directions Apply a nickel thick layer to the affected area s once daily as directed Refills By signing below I verify that the information being disclosed in this enrollment form is complete and accurate to the best of my knowledge. I understand that ASPN Pharmacies LLC ASPN reserves the right at any time and for any reason without notice to modify this enrollment form or to modify or discontinue any services or assistance provided through this Program. Finally I authorize ASPN as my designated agent to use and disclose my patient s protected health information as may be necessary for treatment payment and healthcare operations including to verify the accuracy of any information provided to verify patient eligibility to provide for payment and reimbursement and to forward the above prescription information by fax or other mode of delivery to a pharmacy for fulfillment. Finally I allow ASPN to email me regarding prescription status updates and act as my prior authorization agent in dealing with prescription and medical insurance companies. You should not use emails for emergencies. Prescriber s signature Notes Signature is required to process the prescription. Stamped signatures are not permissible. Therefore there is potential for these unencrypted emails to be intercepted by unauthorized third parties. If you share your email account or computer with others those parties may be able to access your confidential information. You should notify ASPN immediately if you wish to cease receiving emails or if your email address changes.

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