patient information prescriber information …...osteoarthritis enrollment form $ please detach...

Choose Location Osteoarthritis Enrollment Form $ Please detach before submitting to a pharmacy – tear here. PATIENT INFORMATION PRESCRIBER INFORMATION Please complete the following or send patient demographic sheet Patient Name Prescriber’s Name Address DEA Address 2 NPI City, State, ZIP Group / Hospital Home Phone Address Alternate Phone City, State, ZIP DOB Last Four of SS# Gender Phone Fax Language Pref: English Spanish Other Contact Person Phone INSURANCE INFORMATION (Must fax a copy of patient’s insurance card including both sides) Prior Authorization Reference number MEDICAL INFORMATION (Section must be completed to process prescription) (Attach separate sheet if needed) Diagnosis — Please include diagnosis name with ICD-10 code Additional Information Therapy: New Reauthorization Restart ICD-10 Description Afected Joint: Right knee Left knee Both knees Date of Diagnosis PRESCRIPTION INFORMATION Medication Dose / Strength Weight kg / lbs Height cm / in BSA m 2 Allergies Prior Therapies Concomitant Medications Additional Comments Treatment Start Date Treatment End Date Directions Quantity Reflls DUROLANE ® Eufexxa ® Gel-One ® GELSYN-3 ® GenVisc 850 ® Hyalgan ® Hymovis ® Monovisc ® Orthovisc ® Supartz FX ® Synvisc ® Synvisc One ® VISCO-3 ™ * Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), and to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms and the receipt and submission of patient lab values and other patient data. In the event that this pharmacy determines that it is unable to fulfll this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network. Ship to: Patient Ofce Other Date Needs by Date Product Substitution permitted Dispense as Written Prescriber’s Signature Date Supervising Physician Signature Date Electronic or digital signatures not accepted. CONFIDENTIALITY STATEMENT: This communication is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confdential, and exempt from disclosure under applicable law. If the reader of this communication is not the intended recipient or the employee or agent responsible for delivery of the communication, you are hereby notifed that any dissemination, distribution, or copying of the communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone. 58676 080119

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Choose Location Osteoarthritis

Enrollment Form $ Please detach before submitting to a pharmacy – tear here.

PATIENT INFORMATION PRESCRIBER INFORMATION Please complete the following or send patient demographic sheet

Patient Name Prescriber’s Name

Address DEA

Address 2 NPI

City, State, ZIP Group/ Hospital

Home Phone Address

Alternate Phone City, State, ZIP

DOB Last Four of SS# Gender Phone Fax

Language Pref: English Spanish Other Contact Person Phone

INSURANCE INFORMATION (Must fax a copy of patient’s insurance card including both sides)

Prior Authorization Reference number

MEDICAL INFORMATION (Section must be completed to process prescription) (Attach separate sheet if needed)

Diagnosis — Please include diagnosis name with ICD-10 code Additional Information Therapy: New Reauthorization Restart

ICD-10

Description

Afected Joint:

Right knee

Left knee

Both knees

Date of Diagnosis

PRESCRIPTION INFORMATION Medication Dose /Strength

Weight kg / lbs Height cm / in BSA m2

Allergies

Prior Therapies

Concomitant Medications

Additional Comments

Treatment Start Date Treatment End Date

Directions Quantity Reflls

DUROLANE®

Eufexxa®

Gel-One®

GELSYN-3®

GenVisc 850®

Hyalgan®

Hymovis®

Monovisc®

Orthovisc®

Supartz FX®

Synvisc®

Synvisc One®

VISCO-3™

* Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), and to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms and the receipt and submission of patient lab values and other patient data. In the event that this pharmacy determines that it is unable to fulfll this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.

Ship to: Patient Ofce Other Date Needs by Date

Product Substitution permitted Dispense as Written

Prescriber’s Signature Date Supervising Physician Signature Date Electronic or digital signatures not accepted.

CONFIDENTIALITY STATEMENT: This communication is intended for the use of the individual or entity to which it is addressed and may contain information that is privileged, confdential, and exempt from disclosure under applicable law. If the reader of this communication is not the intended recipient or the employee or agent responsible for delivery of the communication, you are hereby notifed that any dissemination, distribution, or copying of the communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone.

58676 080119

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