EnrollmentForm

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

Deliver Medications To: Patient's Home Doctor's Office Date Needed By: __________Pharmacy to arrange injection training? Y N

PATIENT DEMOGRAPHICS

Last Name: First Name: Date of Birth:

Street Address: City:

Home Phone: Cell Phone: Work Phone:

State: Zip:

PLEASE ATTACH A COPY OF THE FRONT AND BACK OF THE PATIENT'S INSURANCE CARD

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

Diagnosis: ___________________

PRESCRIPTION INFORMATION

Cimzia

Dificid

DRUG STRENGTH DIRECTIONS QTY REFILLS

PRESCRIBER INFORMATIONPrescriber Name:Street Address:Office Phone:DEA:Physician Signature: _____________________________

Facility Group or Hospital:

Office Fax:NPI: UPIN:

Date: _____________________________________

State: Zip:

ICD-10 Code: ___________________ Severity: Moderate SevereTB Test Yes No Result: ___________________ Date: ___________________ Sex M F

Does patient have active/serious infection? Yes No Drug Allergies: ________________________________________________

Weight: _______ lbs or kg

Previous/Failed Medications: Date and Duration of Therapy: Reason for Discontinuation:_________________________ _________________________ _________________________

PATIENT SUPPORT AND INJECTION TRAININGI authorize Encompass Rx to enroll patient in the pharmaceutical company-assisted patient support program, corresponding with my prescribed therapy for purposes of receiving additional services such as, but not limited to, injection training. Patient further authorizes Encompassto release and communicate to the corresponding manufacturer the minimum necessary information about their health condition and prescription(s) to: coordinate the delivery of products and services available through the patient assistance program, aggregate de-identified datafor market analysis, contact me occasionally for market research purposes, and provide educational information regarding therapies and disease states. I understand patient make revoke this authorization at anytime in writing by sending a letter to Encompass Rx: 1190 West DruidHills Dr. NE Atlanta, GA 30329. I understand that patient may refuse authorization and that refusal will not affect patient ability to obtain treatment from the pharmacy.

Cimzia Starter Kit

200mg PFS200mg Vial200mg Tablet

HumiraCitrateFree

IBD Starter Pack

40mg Pen40mg PFS

Simponi

Xifaxan

Inject 400mg sc on day 1, at week 2 and week 4, then maintenance doseInduction Dose:

Induction Dose:

Inject 400mg sc every 4 weeksOther: ___________________________________________________________________

Inject 160mg sc on day 1, 80mg sc on day 15, then maintenance dose

Take 1 tablet by mouth twice a day

Inject 40mg sc every 2 weeksOther:__________________________________________________________________

Inject 200mg sc on day 1, 100mg sc on day 15, then maintenance doseInject 100mg sc every 4 weeks

Take 1 tablet by mouth three times a day

_________________________ _________________________ _________________________

IBD

Induction Dose:

Other:__________________________________________________________________

Remicade

Maintenance Dose:

EntyvioInduction Dose:Maintenance Dose:Other: ____________________________________________________________________

300mg Vial300mg IV on weeks 0, 2 and 6

300mg IV q 8 weeks

100mg VialInduction Dose:Maintenance Dose:Other:__________________________________________________________________

IV at 5mg/kg (Each Dose = _____ mg) on weeks 0, 2 and 6IV at 5mg/kg (Each Dose = _____ mg) q 8 weeks

PHARMACY TO WARM TRANSFER THE PATIENT TO HUMIRA COMPLETE

VancomycinClostridium Dificile: Take a 125mg capsule every 6 hours for 10 daysEnterocolitis: Sig. ______________________________________________________

Induction Dose:Maintenance Dose:

Infuse 260mg 390mg 520mg IV on day 0Inject 90mg sc every 8 weeks

Stelara

1 kit

1 pack

3

"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, HMO's, employer group health plans, governmentalhealth programs, or other payors, for the purposes of satisfying such payor's prior authorization requirements with respect to the medication being prescribes for the treatment of our mutual patient."

Primary Prescription Insurance/BIN: ____________________________ Policy Number: ____________________________

PHARMACY TO WARM TRANSFER THE PATIENT TO CIMPLICITY

Inflectra

City:Office Contact:

550mg Tablet

100mg PFS 100mg AutoInjector

130mg Vial90 PFS125mg Capsule250mg Capsule

Xeljanz 5 mg10 mg

10 mg Induction Dose: 10 mg twice a day for _____ weeks

Maintenance Dose: Take 1 tablet twice daily