EnrollmentForm

FAX: 1-855-322-2087PHONE: 1-855-443-9944NPI: 1417216128

Deliver Medications To: Patient's Home Doctor's Office Date Needed By: __________ Inj. Training/Admin. Y N

PATIENT DEMOGRAPHICS

Last Name: First Name: Date of Birth:

Street Address: City:

Home Phone: Cell Phone: Work Phone:

State: Zip:

Prescription Insurance: PLEASE ATTACH A COPY OF THE FRONT AND BACK OF THE PATIENT'S CARD

Primary Prescription Insurance: ___________________________________

Patient ID/Policy Number: ________________________________________

Rx BIN: __________________

Patient Rx Group Number: ________________________________

Rx PCN: __________________

PATIENT CLINICAL INFORMATION/HISTORY: (PLEASE ATTACH A COPY OF PATIENT'S RECENT CHART NOTES, PATHOLOGY AND LABS)

Diagnosis: _______________

PRESCRIPTION INFORMATION

Boniva injection

Forteo

Prolia

Reclast

DRUG STRENGTH DIRECTIONS QUANTITY REFILLS

PRESCRIBER INFORMATION

Prescriber Name:

Street Address:

Office Phone:DEA:Physician Signature: _____________________________

Facility Group or Hospital:

City:Office Fax: Office Contact:NPI: UPIN:

Date: _____________________________________

State: Zip:

ICD-10 Code: _______________

Disease State Description:Postmenopausal osteoporosis with fracture risk (female)Postmenopausal osteoporosis prophylaxisHypogonadal osteoporosis with high fracture risk (male)Glucocorticoid-induced osteoporosis treatment/prophylaxisPaget's diseaseOther: _____________________________________________

Date of Diagnosis: ______________________________________Test Results:

Serum calcium _____________________Scr/CrCl ___________________________BMD______________________________T score ____________________________

WNL:YesYesYesYes

NoNoNoNo

Weight__________kg/lbs Height__________cm/in BSA________m2

Allergies:_________________________________________________

Fracture History:___________________________________________

Prior Failed Therapies:

Concomitant Medications:__________________________________

Additional Comments: _____________________________________

Treatment Start Date: ___________Treatment End Date: __________

Actonel (risedronate)Fosamax (alendronate)Reclast (Zoledronic Acid Injection)

Boniva (ibandronate)Prolia (denosumab)

OSTEOPOROSIS

Inject 20mcg subcutaneous once daily

NEEDLES 31 gauge 5mm 6mm 8mm

600mcg/2.4ml

Use with Forteo Delivery Device as directed

60mg

5mg

Inject 60mg subcutaneous every 6 months

Infuse 5mg IV once a year

1 device(4-week supply)3 device(12-week supply)

4-week supply12-week supply

1 vial

3mg every 3 months administered intravenously overa period of 15 to 30 seconds

3mg PFS

"By signing I hereby authorize Encompass Rx, LLC and its pharmacists, technicians and other employees and agents to disclose, share and submit patient information to health insurers, HMOs, employer group health plans, governmentalhealth programs, or other payors, for the purpose of satisfying such payor's prior authorization requirements with respect to the medication being prescribed for the treatment of our mutual patient."

NEEDLES 31 gauge 5mm 6mm 8mm Use with Tymlos Delivery Device as directed 4-week supply12-week supply

Tymlos 2000mcg/mL Inject 80mcg subcutaneous once daily

1 device(4-week supply)3 device(12-week supply)