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Phone: (877) 868-4110 Fax: (877) 868-4144


Prescribers  and  Staff

YOUR ONE-STOP SOLUTION AMERICAN  SPECIALTY  PHARMACY  is  able  to  assist  you.  We  are  a  Specialty Pharmacy  with  retail  stores  with  the  ability  to  fill  ALL  of  your  patient’s  medications. Attached  you  will  find  a  Prescription  Referral  Form  for  use  with  specific  chronic illnesses.  If  your  patients  also  need  other  medications  not  listed,  just  send  the prescription  along  with  it  and  we’ll  take  care  of  that  too!

Our  goal  is  to  service  all  of  the  needs  of  your  office  and  your  patients.

•  A  member  of  our  team  will  fax  prescription  and  patient  status    updates  throughout  the  prescription  process •  P rior  authorizations  to  initiate  treatment •  R e-­Authorization  to  prevent  therapy  interruption •  C ost  management •  N o  cost  for  delivery  to  patient  home  or  your  office •  I njection  training  for  self  injectable  medications  at  patient    home  or  in  your  office •  D isease  and  treatment  education  prior  to  therapy  initiation •  O ngoing  side  effects  management •  C ustomize  patient  monitoring •  R efill  reminders  and  coordination •  R etail  prescriptions  to  ensure  patients  have  ONE  PHARMACY •  I nfusion  &  Compounding  services  available For  more  information  please  call  or  email: Phone:  (877)  868-­4110     |     Fax:  (888)  294-­9434     |     Email:  info@americanspecialtypharmacy.com

PLANO,TX     |     DENTON,  TX     |     SAN  ANTONIO     |     EL  PASO,  TX     |     TYLER,  TX www.AMERICANSPECIALTYPHARMACY.com


We look forward to serving you and meeting all of your pharmacy needs. OUR PRODUCTS & SERVICES

We are a full service pharmacy that specializes in: Compounded & Specialty Medications Durable Medical Equipment (DME) Nutritional Supplementation Workers’ Compensation Prescriptions Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOU

Our customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire process. From contacting your insurance carrier to automatic re lls and overnight delivery.

www.AMERICANSPECIALTYPHARMACY.com


At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or unavailable medications to meet speci c patient needs. We o er a full line of Professional Quality Vitamins,

Nutritional Supplements, OTC Medications, Everyday Prescriptions, Medical Equipment & Specialty Medications.

COMPLIMENTARY DELIVERY All deliveries are delivered straight to your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLS

Your re lls are lled automatically based on your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION

2743 West 15th Street Plano, TX 75075 P: 877-868-4110 . F: 877-868-4144

EMAIL

info@americanspecialtyrx.com

HOURS OF OPERATION Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm

www.AMERICANSPECIALTYPHARMACY.com


HIV / INFECTIOUS DISEASE Form

Treating Patients Special

American Specialty to Arrange

Ship to:

Pa ent Home

MD

e

CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com

PATIENT INFORMATION (Use this area or

nt demographi s)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or

opy of insuran

Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or

ard(s)

Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________

h pa ent labs and other authoriz

Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________ PRESCRIPTION INFORMATION *(Use this area or Medi

Atripla Combivir Crixivan Emtriva

opy of RX(s)

/ Write in other(s)

Epivir Epzicom Fuzeon Intelence Invirase

Isentress Kaletra Lexiva Norvir Prezista

Rescriptor Retrovir Rayataz Selzentry

Trizivir Truvada Videx EC Viracept Viramune

Other: _______________ Other: _______________ Other: _______________

This is a list of the most common Specialty HIV / Disease medica

Dose / Strength:

American Specialty Pharmacy is available to all of your needs.

Sig /

Re l(s): ____________

Viread Zerit Ziagen

____________

Date: _______________

Prescriber Signature: ___________________________________________________

Please include any other medica your needs including IV

PRESCRIBER INFORMATION

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________

FAX TO: (888) 294-9434 HIVFRMVS.12


MALE HRT REFERRAL FORM

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

▢ ▢

Viagra

DESIGNED SUPPLEMENTS & SUPPLIES ▢

TROCHES/TABLETS ▢

CREAM, GEL & ETC - QTY: 30gm (Thrity Grams) ▢

▢ ▢

CREAM, GEL & ETC - QTY: 60ml (Sixty Milliliters) ▢

INJECTABLE - QTY: 10ml (Ten Milliliters) ▢

COMPOUNDED INTRACAVERNOSAL - QTY: 10ml (Ten Milliliters) ▢ ▢ ▢ ▢

ADDITIONAL NOTES:

Prescriber’s Signature at 888-966-0188


HEPATITIS / CROHNS Form

Treating Patients Special PATIENT INFORMATION (Use this area or

American Specialty to Arrange

Ship to:

Pa ent Home

MD

e

CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com ent demographi s)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________ INSURANCE INFORMATION (Use this area or a

opy of insuran e ard(s)

Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________ MEDICAL ASSESSMENT (Use this area or

Secondary / RX: _____________________________________________ Phone: ____________________________________________________ ID#: _________________________ Group: ______________________

ent labs and other authoriza on informa on)

Primary Diagnosis: _________________________ ICD9 Code: ________________________ Secondary Diagnosis: _______________________ ICD9 Code: ________________________ Genotype: ______ Subtype: ______ Relapsed Par al Response Null Response Liver Biopsy Date: ___________ Result of Biopsy: __________________________________ Previous Treatment: ____________________________________________________________ PRESCRIPTION INFORMATION *(Use this area or

opy of RX(s)

PEGASYS® Pre-Filled Convenience Pack 180mcg (0.5mL) Sub-Q QW Other: ____________________________________ Qty: ______ Re : ______ month(s)

PEG–INTRON® Kg (Lbs) Redipen Vials <40 (<88) Inject 50mcg (0.5mL) Sub-Q QW 40-50 (89-110) Inject 64mcg (0.4mL) Sub-Q QW 51-60 (111-132) Inject 80mcg (0.5mL) Sub-Q QW 61-75 (133-165) Inject 96mcg (0.4mL) Sub-Q QW 76-85(166-187) Inject 120mcg (0.5mL) Sub-Q QW >85 (>187) Inject 150mcg (0.5mL) Sub-Q QW Qty: __________ Re : _______ Month(s)

RIBAPAK® 800mg PO QD: (1)400mg QAM – (1)400mg QPM 1000mg PO QD: (1)400mg QAM – (1)600mg QPM 1200mg PO QD: (1)600mg QAM – (1)600mg QPM 1400mg PO QD: (1)600mg QAM – (1)600mg + (1)200mg QPM Re : _____ Month(s) DO NOT SUBSTITUTE / D.A.W.

HUMIRA® Humira Pen Starter Pack 40mg/pen, 6/box Other: _____________________________________ Sig:

Inject 160mg (4-pens) sub-q ini al dose then 80mg (2-pens) sub-q on day 15 then 40mg (1-pen) sub-q QOW Inject 80mg (2-pens) sub-q QD for 2 days l dose, then 80mg(2-pens) sub-q day 15, then 40mg (1-pen) sub-q QOW 40mg sub-q every 2 weeks 40mg sub-q every week Other: _________________________________

Quan ty: _______

Re : _______

HCV RNA: _________________ Hemoglobin: ______________ Hematocrit: _______________ ALT: _____________________ AST: _____________________

INFERGEN® 9mcg Sub-Q TIW 15mcg Sub-Q TIW 9mcg Sub-Q QD 15mcg Sub-Q QD Other: _______________________________ Qty: _____ Re : _______Month(s) RIBAVIRIN 200mg 600mg PO QD: 200mg-QAM 400mg-QPM Qty: 84 800mg PO QD: 400mg-QAM 400mg-QPM Qty: 112 1000mg PO QD: 400mg-QAM 600mg-QPM Qty: 140 1200mg PO QD: 600mg-QAM 600mg-QPM Qty: 168 1400mg PO QD: 600mg-QAM 800mg-QPM Qty: 196 Other PO QD: _______QAM / ______QPM Qty: ___ Re :_______ Month(s)

CIMZIA® 200mg single dose vials 2/box Qty: ____ boxes 200mg single use PFS 2/box Qty: ____ boxes Sig: Ini al dose: 400mg sub-q at week 0, 2, and 4 Maintenance: 400mg sub-q every 4 weeks Re : _________ REMICADE® Single use 100mg vial #____vials Excel sodium chloride 250ml bag #____bags Sterile water / injec on 10ml/vial #____vials Normal saline 10mL/PFS #____syringes Epipen® Benadryl® 50mg vial PRN Direc : __________________________________ Re : __________

VICTRELIS® 200mg caps 800mg PO TID: (4)200mg caps Q7-9hrs w/ food. Begin day 29 of interferon/ribavirin Qty: 336 Re : _______

INCIVEK® 375mg tabs 750mg PO TID: (2)375mg tabs Q7-9hrs w/ food for 12 weeks with interferon/ribavirin Qty: 168 tablets Aranesp® Neulasta®

Re : _______ Epogen® Neupogen®

Dose: ___________________ Sig: ________________________ Qty: ______

Re : ______

HEPATITIS B ORAL THERAPIES Baraclude 1 Tablet po QD 0.5mg 1.0mg Epivir HBV 100mg __________ Hepsara 10mg _____________ Tyzeka 600mg _____________ Viread 300mg _____________

Signature: _________________________________ Date: _________

PRESCRIBER INFORMATION

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________

FAX TO: (888)294-9434

HCVFRMVS.912


hCG REFERRAL FORM

PRESCRIPTION

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

Injectable: *Administer daily or bi-weekly

30

Slim Shots: *Inject as directed

40

Sublingual Drops: *Administer sublingually 4 drops a day 30

40

Nasal Spray (not available for hypogonadism) *Administer one spray per nostril daily 30

Today’s Date

ADDITIONAL NOTES:

40

Prescriber’s Signature IMPORTANCE NOTICE:

at 888-966-0188


COMPOUNDED INTRACAVERNOSAL

PRESCRIPTION

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

MIX: -

BI-MIX:

TRI-MIX:

QUATRO-MIX:

ADDITIONAL NOTES:

Prescriber’s Signature

at 888-966-0188


www.AMERICANSPECIALTYRX.com Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston


HIV / Infectious Disease