Download Patient

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