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Fax to: 1-800-479-2562 Number of pages in fax: Phone: 1-800-645-1280 Pediatric Patient Information Adult Patient Name (First and Last) Date of Birth XX/XX/XX Address: City Home Phone Work Phone Cell Phone Gender Current Height cm % State ZIP Parent/Guardian Name (if under 18 years of age) M F Current Weight Primary Language kg % Allergies None Other List of medications Insurance Information or Attach Legible Copy of Front and Back of Insurance Card Diagnosis Please see attached checklist for diagnosisspecific documentation requirements Primary Insurance Patient ID # Insurance Company Phone Pharmacy Insurance Pharmacy ID # Pharmacy Benefit Manager Phone No insurance Panhypopituitarism (253.2) Turner Syndrome (758.6) Isolated Growth Hormone Deficiency (253.3) Prader-Willi Syndrome (759.81) SGA Recommended ICD-9: Growth Failure (783.43) plus Small for Dates (764.00) or Fetal Growth Retardation, Unspecified (764.90) Iatrogenic Hypopituitarism with growth-related disorder (253.7): hypophysectomy-induced, postablative, or radiotherapy-induced Short Stature/Growth Failure (783.43) Idiopathic Short Stature Other FDA-Approved Diagnosis (ICD-9 Code) See reverse for additional weight-based SGA codes. Prescription Options for GENOTROPIN® (choose A, B, C, or D, plus choose pen needle or insulin syringe size) A. GENOTROPIN Pen® 5 B. GENOTROPIN Pen® 12 C. GENOTROPIN MiniQuick® D. GENOTROPIN Mixer® Growth Hormone Delivery Device Growth Hormone Delivery Device Reconstitution Device (dose in increments of 0.1 mg) (dose in increments of 0.2 mg) is available in 10 strengths, each in a package of 7. After reconstitution, each strength delivers a fixed volume of 0.25 mL. 5 mg GENOTROPIN (5 mg/mL) 12 mg GENOTROPIN (12 mg/mL) Pen Needle Gauge 29 0.2 mg 0.8 mg 1.4 mg 2.0 mg Pen Needle Gauge 31 29 Please select strength 31 0.4 mg 1.0 mg 1.6 mg Choose Cartridge 5 mg GENOTROPIN (5 mg/mL) 12 mg GENOTROPIN (12 mg/mL) 0.6 mg 1.2 mg 1.8 mg Insulin Syringe 0.3 mL 0.5 mL 1.0 mL Pen Needle Gauge 29 31 Other Dental Needles Dose to Be Given Subcutaneously Special Instructions (check all applicable boxes) Physician Certification Daily Dose mg/day days/wk One-on-one Nurse-to Patient Training Requested Case Management Not Requested GENOTROPIN Copay Program Requested Interim Care (pediatric patients only) Days Supply 30 90 Refills Preferred Pharmacy Other MiniQuick Instructional Brochure and DVD (sent directly to patient) 1) I certify that the treatment listed above is and will be medically necessary based on my best professional judgment, and that the information provided above is complete and accurate to the best of my knowledge. 2) I also certify that I have obtained the written permission of the patient (or the patient’s legal representative) to disclose the information here and such other health or personal information to the Pfizer Bridge Program® (the “Program”), Pfizer, and/or its agents as may be necessary for the patient’s participation in the Program and for the Program. Pfizer and/or its agents may use such information as necessary to provide reimbursement support and other patient management services to me and the patient in connection with the patient’s GENOTROPIN therapy. (A signed copy of a Pfizer Bridge Program Patient Authorization Form [the “Authorization”] either accompanies this completed Statement of Medical Necessity or, to the best of the undersigned’s knowledge, is already on file with the Pfizer Bridge Program.) I understand that the Program may use and disclose this information only in accordance with the Authorization. 3) I further certify that (a) any service provided through the Program on behalf of any patient is not made in exchange for any express or implied agreement or understanding that I would recommend, prescribe, or use GENOTROPIN or any other Pfizer product or service for anyone and (b) my decision to prescribe GENOTROPIN was based on my determination of medical necessity as set forth herein. 4) I authorize and appoint the Program to convey prescriptions delivered to the Program for GENOTROPIN to the applicable dispensing pharmacy on my behalf. 5) I certify that if I have prescribed treatment for adult Growth Hormone Deficiency (GHD) it was confirmed through growth hormone stimulation testing or by other organic/clinical evidence of adult GHD (such as the lack of a pituitary gland). Signature†‡ __________________________________________________________ Date: Print/Type Name National Provider ID (NPI) Address City State Office Contact Phone Fax *Certain programs and services powered by Pfizer RxPathways TM. † This form cannot be processed without physician’s signature. ‡ In New York, please attach copies of all prescriptions on Official New York State Prescription forms. Please see accompanying full Prescribing Information and Instructions for Use. DEA # ZIP The following is a list of what needs to accompany the SMN, by diagnosis. Please note that some payers may require additional information. Your patient’s PCC will notify you in those situations. PEDIATRIC Isolated GH Deficiency (253.3) Iatrogenic-induced Hypopituitarism with growth-related disorder (253.7) Two stim test results IGF-I and IGF-BP3 results Growth chart Bone age History and physical MRI of brain/pituitary Date: MRI Date: List of hormonal deficiencies and/or replacements History, physical, and cause DEXA Stim test results Prader-Willi Syndrome (PWS) (759.81) Genetic testing Growth chart Current height/weight Parental height Bone age IGF and stim testing are not required. Small for Gestational Age (SGA) (764.00) Growth charts from the age of 2 years Gestational age Birth weight/length Current height/weight IGF and stim testing are not required. Additional SGA weight-based codes Fill in the “Other FDA-Approved Diagnosis” field on front with the appropriate code as needed. 764.91 764.92 764.93 764.94 764.95 764.96 764.97 764.98 764.99 Fetal growth retardation less than 500 grams Fetal growth retardation less than 750 grams Fetal growth retardation less than 1000 grams Fetal growth retardation less than 1250 grams Fetal growth retardation less than 1500 grams Fetal growth retardation less than 1750 grams Fetal growth retardation less than 2000 grams Fetal growth retardation less than 2500 grams Fetal growth retardation 2500 grams and over Idiopathic Short Stature (ISS) (783.43) Bone age Growth chart Current height/weight Parental height MRI of brain/pituitary Date: Two stim test results IGF-I and IGF-BP3 results Predicted height Turner Syndrome (758.6) Growth chart Current height/weight Parental height Bone age Genetic testing Panhypopituitarism related to growth disorder (253.2) Growth chart Current height/weight Bone age MRI of brain/pituitary Date: Laboratory testing: (LH, FSH, GH, TSH, Free T4, T3) ADULT Isolated GH Deficiency (253.3) Panhypopituitarism related to growth disorder (253.2) Two stim test results IGF-I and IGF-BP3 results History of head trauma DEXA scan History and physical MRI of brain/pituitary Date: Lipid profile Thyroid report MRI Date: List of hormonal deficiencies and/or replacements History and physical DEXA scan Lipid profile Thyroid report If any of the above medical documentation is not available, please let us know if the testing has already been scheduled or will not be performed, or if your office is waiting on the testing results from another facility. Please see accompanying full Prescribing Information and Instructions for Use. GNU709403-01 © 2014 Pfizer Inc. All rights reserved. December 2014