Best Phone #: ... 250mg Vial (IV use only) ... myHUMIRA Nurse (RN) visit to provide education & training : Patient's
Form from www.needymeds.org
Single Point of Contact for Office 877.575.SPOC (7762) **FAX: 877.301.8207**
Rheumatology Reset Form Referral Form
Patient Information
Date:________________ Patient SS#:________________________________ Male Female Patient’s First Name:___________________________________ Patient’s Last Name:___________________________________________________ Address:____________________________________________ City:______________________________________ State:________ Zip:__________ Best Phone #:_______________________________________________ Alternate Phone #:_______________________________________________ DOB:_______________ Caregiver:______________________ Allergies:_______________________Latex Allergy: Yes No Date of Negative TB Test:________________Hep B ruled out: Yes No If no, Treatment started? : Y / N Patient Weight: _______ kg / lb
Clinical
INSURANCE INFORMATION: PLEASE FAX COPY OF INSURANCE CARD (FRONT & BACK) 714.0 Rheumatoid Arthritis 696.0 Psoriatic Arthritis Diagnosis: Date of Diagnosis or Years with Disease:_________________________
720.0 Ankylosing Spondylitis
Other_______________
Acetaminophen, ibuprofen, naproxen, aspirin Humira Enbrel- Methotrexate Corticosteroids Celebrex Prior Medications: Indocin Azulfidine Other meds tried: _____________________Add’l justification for med:______________________________ Yes Current Medications:________________________________________________________ Is patient also taking methotrexate?
Humira Injection Training or Nurse Support: *Physician Signature required for Injection Training* myHUMIRA Nurse (RN) visit to provide education & training : Patient’s Home or Clinic Site Physician’s Office
No Nurse
Simponi Injection Training or Nurse Support: SimponiOne RN to provide education & training for Sub-Q injection
No Nurse
Date Shipment Needed:_________________ Ship to: ______Patient _____Physician/Clinic Ship to Other:______________________________________________________________________________________________________________ Physician Name (please print): _____________________________________________________ Contact Name: _____________________________ Phone #: _________________________________ Fax #: ___________________________________NPI #: ________________________________ Office Address______________________________________________City: _________________________State: _________Zip: _______________ I authorize Diplomat and its representatives to act as an agent to initiate and execute the insurance prior authorization process.
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