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Oncology Oral Medications

Fax Referral To: 888-280-1191 Toll Free Phone: 888-280-1190

Ship to: Patient Office Other: PATIENT INFORMATION

(Complete the following or send patient demographic sheet)

280 Avenida Jesus T. Pinero, Suite B Rio Piedras, PR 00927 Local Phone: 787-759-4162 Local Fax: 787-759-4090

Enrollment Form

Date: Needs by Date:

PRESCRIBER INFORMATION Prescriber's Name: State License #: DEA #: Group or Hospital: Address: City, State Zip: Phone: Contact Person:

ID#: ID#: ID#: BIN: Name of Insurer: Name of Insurer: PCN:

Patient Name: Address: City, State, Zip: Home Phone: Alternate Phone: SS #: Date of Birth:

Prescription Card: Primary Insurance:

UPIN: NPI #:

Primary Language:

Fax: Phone:

Group: Phone: Phone:

Gender:

Name of Insurer: Subscriber: No

INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card)

Secondary Insurance: Subscriber: Yes Is the patient eligible for Medicare? Diagnosis Description: Diagnosis Description: Other Clinical Information/Comments: Weight: kg Other Conditions: Other Medications: Allergies:

Previous Therapies:

STATEMENT OF MEDICAL NECESSITY

Diagnosis (ICD-9 code): Diagnosis (ICD-9 code): lbs Height: inches cm BSA: Date of Diagnosis: Date of Diagnosis: m2

No Known Drug Allergy

Test Results: Serum Creatinine: Liver Function: Potassium:

WNL Yes Yes Yes

No No No

Magnesium: ECG: Baseline BP:

WNL Yes Yes Yes

No No No

PRESCRIPTION INFORMATION

MEDICATIONS Revlimid -RevAssist Thalomid -STEPS Program Pregnancy Category: Adult Female ­ Childbearing Potential Female Child ­ Childbearing Potential Afinitor (everolimus) Oforta® (fludarabine) TarcevaTM (erlotinib HCL) Thalomid® (thalidomide) Zolinza® (vorinostat) Adult Female ­ NOT of Childbearing Potential Female Child ­ NOT of Childbearing Potential Hycamtin Capsules® (topotecan) SprycelTM (dasatinib) Tasigna® (nilotinib) Votrient® (pazopanib) Other: Adult Male Male Child Nexavar® (sorafenib) Sutent® (sunitinib malate) Temodar® Capsules (temozolomide) Xeloda® (capecitabine)

® ®

Physician Auth#: Physician Auth#:

Date: Date:

Revlimid Diagnosis:

MDS 238.7 MM 203.0

Gleevec® (imatinib mesylate) Revlimid® (lenalidomide) Targretin Capsules (bexarotene) Tykerb® (lapatinib) ZytigaTM (abiraterone)

STRENGTH

SIG./DIRECTIONS

Refills:

Quantity:

Please enroll my patient into the following manufacturer patient support program:

I hereby freely and voluntarily have selected CVS Caremark and/or CarePlus CVS/pharmacy to dispense the medication herein prescribed by my physician. Patient Signature: ______________________________________________________________________________________________________________

Physician's Signature

X

PRODUCT SUBSTITUTION PERMITTED (Date)

X

DISPENSE AS WRITTEN (Date)

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the

recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Oncology Orals 060711

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