Phone: (877) 868-4110 Fax: (877) 868-4144

Prescribers and Staff

YOUR ONE-STOP SOLUTION

Our goal is to service all of the needs of your office and your patients.

• A member of our team will fax prescription and patient status updates throughout the prescription process• Prior authorizations to initiate treatment• Re-­Authorization to prevent therapy interruption• Cost management•• No cost for delivery to patient home or your office• Injection training for self injectable medications at patient home or in your office• Disease and treatment education prior to therapy initiation• Ongoing side effects management• Customize patient monitoring• Refill reminders and coordination•• Retail prescriptions to ensure patients have ONE PHARMACY• Infusion & Compounding services available

AMERICAN SPECIALTY PHARMACY is able to assist you. We are a SpecialtyPharmacy with retail stores with the ability to fill ALL of your patient’s medications.

Attached you will find a Prescription Referral Form for use with specific chronicillnesses. If your patients also need other medications not listed, just send the

prescription along with it and we’ll take care of that too!

For more information please call or email:

Phone: (877) 868-­4110 | Fax: (888) 294-­9434 | Email: info@americanspecialtypharmacy.com

PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX

www.AMERICANSPECIALTYPHARMACY.com

2743 W. 15th St., Plano, TX 75075Ph: 877-868-4110 Fax: 877-868-4144

INJECTABLE LIST

BetamethasoneAcetate/Phospate (Soluspan)6mg/ml P/F

2ml vial5ml vial10ml vial

Size

Betamethasone Sodium Phospate12mg/ml P/F

2ml vial (min 20 vials)5ml vial (min 6 vials)

Size

Chondroitin / Glucosamine / DMSO

2ml vial (min 3 vials)Size

Hyaluronidase150u/ml P/F

10ml vial preservative freeSize

Dexamethasone (Decadron equiv.)P/F same price as Triamcinolone(same min. quantities applyTriamcinolone Acetonide P/F 40mg/ml P/F

1ml vial (min 20 vials)2ml vial (min 20 vials)

Size

Methylprednisolone Suspension40mg/ml and 80mg/ml P/F

2ml vial (min 20 vials)5ml vial (min 6 vials)10ml vial (min 6 vials)

Size

Ondansetron2mg/ml

2ml vial (min 50 vials)Size

Midazolam* 1-5mg/ml

1-2ml vial (min 50 vials)Size

Fentanyl*50mcg/ml

2ml vial (min 50 vials)Size

Sodium Bicarbonate 4.2% - 8.4%

Size 50ml vial (min 12 vials)Lidocaine 1-2%

Size 50ml vial (min 12 vials)

PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI

OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:

Compounded & Specialty MedicationsDurable Medical Equipment (DME)

Nutritional SupplementationWorkers’ Compensation Prescriptions

Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOUOur customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire

process. From contacting your insurance carrier to automatic re lls and overnight delivery.

We look forward to serving you and meeting all of your pharmacy needs.

www.AMERICANSPECIALTYPHARMACY.com

HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm

COMPLIMENTARY DELIVERYAll deliveries are delivered straight to

your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLSYour re lls are lled automatically based on

your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION2743 West 15th Street

Plano, TX 75075P: 877-868-4110 . F: 877-868-4144

EMAILinfo@americanspecialtyrx.com

At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe

and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or

unavailable medications to meet speci c patient needs.

We o er a full line of Professional Quality Vitamins, Nutritional Supplements, OTC Medications, Everyday

Prescriptions, Medical Equipment & Specialty Medications.

www.AMERICANSPECIALTYPHARMACY.com

PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟĞnt demographiĐs)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________

INSURANCE INFORMATION (Use this area or ĂƩĂĐŚ Đopy of insuranĐĞ Đard(s)

Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________

MEDICAL ASSESSMENT (Use this area or ĂƩĂĐh paƟent labs and other authorizĂƟŽŶ ŝŶĨŽƌŵĂƟŽŶͿ

Primary Dx: ___________________________________ ICD9 Code: ________________________ Secondary Dx: _________________________________ ICD9 Code: ________________________ Previous Treatment: ______________________________________________________________ Previous Treatment Outcome:______________________________________________________ Is ƉĂƟĞŶƚ currently on Therapy? YES NO Med(s): _________________________________

PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s)

ΎWƌĞƐĐƌŝďĞƌ Signature: ______________________________________________ Date: ___________________

Avonex

Betaseron

Copaxone

PreĮůůed Syringe Vials 30mcg

30mcg IM QW Other: _____________________________

Qnty: ReĮůů:

Qnty: ReĮůů: Betaject Lite Week 1&2 0.0625mg (0.25ml) SQ QOD Week 3&4 0.125mg (0.5ml) SQ QOD Week 5&6 0.1875mg (0.75ml) SQ QOD Week 7+ 0.25mg (1ml) SQ QOD 0.25 mg (1ml) SQ QOD

Copaxone Autoject 20mg SQ QD

Qnty: ReĮůů:

Rebif 22mcg/0.5ml

MSFRMVS.912

MULTIPLE SCLEROSIS / NEUROLOGY WƌĞƐĐƌŝƉƟŽŶ Form

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________

Relapsing RemiƫŶŐPrimary Progressive Secondary Progressive Progressive Relapsing Other: ______________

Extavia

Week 1&2 0.0625mg (0.25ml) SQ QOD Week 3&4 0.125mg (0.5ml) SQ QOD Week 5&6 0.1875mg (0.75ml) SQ QOD Week 7+ 0.25mg (1ml) SQ QOD 0.25 mg (1ml) SQ QOD Other: _______________________________________________________

Qnty: ReĮůů:

Gilenya 0.5mg Capsule PO QD Other: ____________________________________________________

Qnty: ReĮůů:

Rebiject Auto InjecƟŽn Week 1&2 4.4mcg (0.1ml) SQ TIW Week 3&4 11mcg (0.25ml) SQ TIW Week 5+ 22mcg (0.5ml) SQ TIW Other: _________________________________________________________

Qnty: ReĮůů:

Rebif 44mcg/0.5ml

Rebiject Auto InjecƟŽn Week 1&2 8.8mcg (0.2ml) SQ TIW Week 3&4 22mcg (0.5ml) SQ TIW Week 5+ 44mcg (0.5ml) SQ TIW Other: _________________________________________________________

Qnty: ReĮůů:

Other: Dose / ŝƌĞĐƟŽns: Qnty: ReĮůů:

Other: Dose / ŝƌĞĐƟŽns: Qnty: ReĮůů:

Treating Patients SpecialShip to: PaƟent Home MD KĸĐe

/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange

FAX TO: (888) 294-9434

CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

NEUROLOGY & PAIN REFERRAL FORM

PRESCRIPTION

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SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽdžLJͲͲ'ůƵĐŽƐĞнϯйĐLJĐůŽǀŝƌ

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NEUROPATHIC PAIN & ANTI - INFLAMMATORY SPRAY:ΎƉƉůLJϯ;ϭŵůͿƐƉƌĂLJƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϰƟŵĞƐĚĂŝůLJͲ&ůƵƌďŝƉƌŽĨĞŶϳϱйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнDĞŶƚŚŽůϯйн>ŝĚŽĐĂŝŶĞϮϬйнD^KͲ<ĞƚĂŵŝŶĞϮϬйнDĞƚŚLJů^ĂůŝĐLJůĂƚĞϯϬйнDĞŶƚŚŽůϯйнD^KͲdƌĂŵĂĚŽůϮϬйнLJĐůŽďĞŶnjĂƉƌŝŶĞϮйнWƌŝŽůŽĐĂŝŶĞϮϱйн>ŝĚŽĐĂŝŶĞϭϮϱйнDĞŶƚŚŽůϯйMIGRAINE HEADACHE:ΎWůĞĂƐĞƐƉĞĐŝĨLJĚŽƐĞĂŶĚĨƌĞƋƵĞŶĐLJͲƌŐŽƚĂŵŝŶĞϭŵŐĂīĞŝŶĞϭϬϬŵŐĞůůĂĚŽŶŶĂϭϬŵŐĂƉƐƵůĞͲƌŐŽƚĂŵŝŶĞdĂƌƚƌĂƚĞϮŵŐ^ƵďůŝŶŐƵĂůdĂďůĞƚƐ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

Cream Size (Pump): 75gm (Seventy-Five Grams)ϭϬϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ'ƌĂŵƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ^ŵĂůůĞƐƚ^ŝnjĞϱϬŐŵ;&ŝŌLJ'ƌĂŵƐͿ

Spray Size:ϲϬŵů;^ŝdžƚLJŵŝůůŝůŝƚĞƌƐͿϭϮϬŵů;KŶĞŚƵŶĚƌĞĚdǁĞŶƚLJŵŝůůŝůŝƚĞƌƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

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