Microsoft word - transplant form 201308.docx

Transplant Order Form
2506 Lakeland Drive, Suite 201, Jackson, Mississippi 39232 Pharmacy phone: (866) 420-4041 Pharmacy fax: (601) 420-4040 Patient Information
Prescriber Information
Patient name ___________________________________________________________ Prescriber name________________________________________Lic#_________________ ess_______________________________________________________________ DEA#____________________________________Tax ID____________________________ City_________________________________________State_________Zip__________ Transplant Center___________________________________________________________ Home phone___________________________ Cell_____________________________ Contact____________________________________Pager___________________________ DOB_______________________ SSN_______________________________________ Address________________________________________________Rm/FL______________ Drug allergies___________________________________________Male Female City___________________________________________State_________Zip____________ ge date_____________________________________Time_________________ Office Phone_____________________________ Fax_______________________________ Emergency Contact Name/Phone __________________________________________ Insurance, Medicare or Medicaid Information
Primary Insurance________________________________________________________ Secondary Insurance( If applicable,)_____________________________________________ Policy #________________________________Group____________________________ Policy #___________________________________Group____________________________ Prescripti  on Drug Coverage: Company___________________________________________________________ Phone____________________________________________________ RXGRP#___________________________________________RXBIN# ________________________________PCN/ID# (if avail.)_____________________________________________ COMPLETE OR FAX FRONT AND BACK COPIES OF INSURANCE , PRESCRIPTION AND/OR CO-PAY ASSISTANCE CARD(S) Clinical Information
Medical Necessity
Additional Information
Transplant date: _______/_______/_______ Was there a prior transplant failure of the same organ?  Yes  No Did patient have Medicare A coverage at time of transplant?  Yes  No Will patient be enrolled in Medicare B at time of discharge?  Yes  No Other:____________________________________ICD-9:_______ Comments__________________________________________________________   Drug Name
Strength
Directions for Use
Refills DAW*
Cellcept ® (Mycophenolate Mofetil) * * In compliance with applicable state regulations and most insurer policies, Transcript Pharmacy will dispense available FDA-approved generic equivalents, unless DAW is indicated.
Deliver to:  Patient’s home  Discharge Rx’s to Hospital, then remaining refills to patient’s home *PRODUCT SUBSTITUTION PERMITTED UNLESS OTHERWISE INDICATED 
All discharge orders include: BP Cuf , digital thermometer, medical alert ID bracelet 7 Day QID pill box
By signing this form and utilizing our services, you are authorizing Transcript Pharmacy, Inc., its agents and employees, to serve as your prior authorization designated agent in dealing with
medical or prescription claims payors, processors and other entities.
_____________________________________ _______________________________________________ _________________________________ ________________
Prescriber name or signature
Office Contact Name (Nurse, MA, Other)
Preferred phone number & extension Date

Source: http://www.transcriptpharmacy.com/forms/TRANSPLANT_Form_201308.pdf