Download Rx Program Gelclair Prescription Form

Rx Program
Gelclair Prescription Form
Fax:
516-308-4339
877-954-6336
Phone:
E-prescribe: Linden Care
NPI# 1790960458
NABP# 3357387
Today’s Date: (mm/dd/yyyy)_________________________
Patient Information:
Sex: M F
Patient Name: First:_________________ Last:____________________ Date of Birth (mm/dd/yyyy): ____/____/____
Address: __________________________________________________City: _________________________State:______ Zip:_____
Cell Phone #: ____________ Home Phone #: ____________ Work Phone #:_______________ Email:_________________________
Insurance Information: Please provide a copy of the patient's insurance card with this form (REQUIRED)
Primary Insurance Policyholder: ______________________ Relationship: __________ Policy#: __________ Group#:_____________
Phone #: _______________ Address: ____________________________ City: __________________ State: _____ Zip: __________
Co-pay Assistance: Zero ($0) co-pay assistance will automatically be applied for commercially insured patients*
Initial 30-Day Prescription: 90 packets, Dose: 1 packet TID or as needed
Refills:
1
2
3
4
Diagnosis Information: _______________________
Stage: ___________________________ ICD-10:_____________________Allergies: ____________________________________
Other medications prescribed for same diagnosis: _____________________________________________________
Oral Mucositis Diagnosis: (Check all that apply)
Code
ICD-10 K12.30
ICD-10 K12.31
Description
ICD-10 K12.32
Mucositis due to other drugs
Mucositis due to antineoplastic therapy such as Radiation therapy
ICD-10 K12.33
ICD-10 K12.39
ICD-10 K13.29
Stomatitis and mucositis unspecified
Mucositis due to antineoplastic therapy such as Antineoplastics
Other oral mucositis (ulcerative)
Other disturbances of the oral epithelium, including tongue
PUHVFULEHU Information:
PUHVFULEHU NameDesignation:______________________B_____________________BBBB_____BBBB_ 2IILFH&RQWDFW1DPH:__________________
Street: _______________________________________________________________________________ City: ___________________________________6WDWH:_________Zip:____________
3KRQH:__________________________Fax:_____________________________(PDLO#:_BBBBBBBBB_______BBB____________________
Prescriber Signature:__________________________________________________________ NPI#:______________
Gelclair Shipping Instructions:
Ship to (please circle): Patient
Physician's Office Other (please specify below)
Other shipping address: ______________________
Date Required (mm/dd/yyyy): _______________
Fax prescription form to: 516-308-4339
E-prescribe: Linden Care Pharmacy NPI# 1790960458 NABP# 3357387
Call with questions: 877-954-6336
Zip Code Look-up 11797
*Copay assistance not valid for prescriptions reimbursed in whole or in part under Medicaid, Medicare, including Medicare Advantage and Part D
Rx drug plans, or any other federal or state programs (including state pharmaceutical assistance programs) or where prohibited, taxed, or
otherwise restricted. Non-insured patients will be enrolled in the Gelclair Patient Assistance Program (PAP), pending income verification.
GELCLAIR® is a registered trademark of Helsinn Healthcare SA, Lugano, Switzerland.
Marketed and distributed by: Midatech Pharma US Inc., 8601 Six Forks Road, Suite 160, Raleigh, NC 27615 under license of Helsinn Healthcare SA, Switzerland.
© 2016 Midatech Pharma US Inc. All rights reserved.
GEL004 Rev 02/16