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Workers Comp | Litigation | Motor Vehicle | Personal Injury | LOP | Auto Injury

Plano Ph: (214) 919-2090 Fax: (214) 919-2091 San Antonio Ph: (210) 615-7400 Fax: (210) 615-7401

Denton Ph: (940) 383-1222 Fax: (940) 383-1444 El Paso Ph: (915) 860-7225 Fax: (915) 860-7320

Miami Ph: (305) 856-0070 Fax: (305) 856-0072

Houston Tyler

WE HELP SET UP YOUR PRESCRIPTION

HASSLE FREE WE INSURANCE WECALL CALLYOUR YOUR ATTORNEY& &ATTORNEY INSURANCE

INJURED PERSON

WE DELIVER RIGHT TO YOUR DOOR

phone calls and paperwork”

Assistance is only a Phone Call away!

WE TAKE CARE OF YOUR REFILLS Open 7 Days a Week Corporate Office

Contact Us at: info@AmericanSpecialtyPharmacy.com lop@AmericanSpecialtyPharmacy.com Tel: (877) 753-6877 Fax: (888) 966-0188

2743 West 15th Street, Plano, TX 75075 Toll Free: 877-753-6877 www.AmericanSpecialtyPharmacy.com

PLEASE HAVE THE FOLLOWING INFORMATION AVAILABLE:

• Name, address and phone number.

• Employer & Insurance carrier name, address, phone number, adjuster name and claim number. • Doctor’s name, phone number and being prescribed.

Tel: (877) 753-6877 Fax: (888) 966-0188


CONVENIENCE IS OUR BUSINESS About Us • American Specialty Pharmacy is one of the leading providers of pharmaceu services in the United States. Our knowledge and exper in the business makes us recognizable in the industry. pharmaceu

• At American Specialty Pharmacy, we are

dedicated to address the well-being of our customers. We are driven by our commitment to be the best and strive to bring the best services and solu to all our clients.

solu

r all your prescrip

• Our dedicated staff works diligently to reduce the stress, put into handling each claim.

• Assist with complicated claim forms • No Out-of-pocket expenses* • FREE Home Delivery Service Assis ng the

.

• By allowing us to manage your clients

department will promptly and carefully a end all phone calls, faxes, and requests.

American Specialty Pharmacy is able to assist you in resolving all injury claims. •Handle all Insurance Paperwork •Hassle Free Delivery •Drug Formulary Management &

• We will ensure that your clients' have all their prescrip completely sa

.

t and are

Data Maintainance & Side-Effect

Management

the client's needs.

We can also fill your regular prescriptons with a simple transfer.

*On approved claims

For the Physicians

orney

• Our experienced customer service

t that is

• We will CUSTOMIZE our services to fit

Our professional and courteous staff will ensure that your prescrip in a .

prescrip providing the best possible care for their other medical needs.

Why choose us?

• We are a FULL SERVICE, ONE STOP

Taking care of the t

*On approved claims

•Compounding & Infusion Services (supplements available upon request)


PLANO | EL PASO | SAN ANTONIO HOUSTON | TYLER | DENTON | MIAMI www.AMERICANSPECIALTYPHARMACY.com PHONE: (877) 753-6877 FAX: (888) 966-0188

www.AMERICANSPECIALTYRX.com


HOW IT WORKS: AUTO INJURY, WORKERS COMP

behalf

‡Upon receiving the prescription, we call you to schedule delivery  (If you don’t hear from us within 24 hours, please contact our pharmacy)

(If applicable)

‡We file the insurance claim on your or bill your attorney 

‡Automatic prescription refills(if necessary)



‡

no out-of-pocket expenses*

FREEDelivery within 24 hours &

*On approved claims

We can also fill your regular prescriptions with a simple transfer


Treating  Patients  Special  

    American Specialty Pharmacy has 4 Pharmacists on site to help ensure quality of compounded products.

American Specialty Pharmacy has Two “State of the Art” ISO-5 Class-100 clean rooms. One for compounding all sterile preparations & one negative pressure chemo room for compounding Chemotherapy medications.

American Specialty Pharmacy is fully compliant with USP797

E-Prescribing capability with real time order entry and tracking system

Specialized Customer Service

One stop for all your Pharmaceutical needs

For all questions or concerns please feel free to call us any time at (877) 753-6877

Pharmacy Locations Plano 2743 W. 15th Street Plano, TX 75075 Ph: (214) 919-2090 Fax: (214) 919-2091

Denton 2436 S. Interstate 35E Suite 360 Denton, TX 76205 Ph: (940) 383-1222 Fax: (940) 383-1444

San Antonio 2414 Babcock Rd. Suite 111 San Antonio, TX 78229 Ph: (210) 615-7400 Fax: (210) 615-7401

Tyler 1109 E. 5th Street Tyler, TX 75701 Ph: (903) 533-9100 Fax: (903) 533-9101

El Paso 1015 N. Zaragoza St. El Paso, TX 79907 Ph: (915) 860-7225 Fax: (915) 860-7320

Miami 2389 SW 22nd Street (Coral Way) Miami, FL 33145 Ph: (305) 856-0070 Fax: (305) 856-0072


2743 W 15th Street, Plano, TX 75075 P: 214-919-2090 Fax: 214-919-2091

New Work Comp / PIP / LOP Information Today’s Date:____________________________ Date Of Injury:____________________________________ Patient’s Name:___________________________________________________________________________ Street Address:___________________________________________________________________________ City:______________________________ State:________________________

Zip Code:______________

Patient’s Home Phone:_________________________________ Cell:_______________________________ Patient’s Date Of Birth:_________________________________ Patient’s SSN:_______________________ Injured Body Area:________________________________________________________________________ Employer:______________________________________________________________________________ Street Address:__________________________________________________________________________ City:______________________________ State:________________________ Zip Code:_____________ Phone:______________________________________ Fax:______________________________________ Supervisor’s Full Name:___________________________________________________________________ WC Insurance Company:__________________________________________ Claim#:_________________ Street Address:__________________________________________________________________________ City:__________________________________________ State:_____________ Zip Code:_____________ Phone:______________________________________ Fax:______________________________________ Adjuster’s Full Name:_____________________________________________________________________ Phone Number:______________________________________________________ Ext#: ______________ Attorney’s Full Name:______________________________________________________________________ Phone Number: _________________________________ Fax: ____________________________________ Adress: ________________________________________________________________________________

Notes / Delivery Notes: ________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ www.AmericanSpecialtyPharmacy.com


LETTER OF PROTECTION/LIENS SCRIPT PAD Ship to:

P: 877-753-6877 Fax: 888-966-0188 info@AmericanSpecialtyRX.com

Patient Home

MD Office

Patient Name _____________________________________ DOB ____________ Weight ________  Male  Female Street Address ________________________________________________________________________________________ Apt # _________ City ___________________________________________ State ____________________ Zip ___________ Phone: __________________________________________________ Cell ________________________________________ Attorney:_________________________________________DOI:________________________________________________ Phone:______________________________________________________Fax:_____________________________________ Prescriber’s Name _____________________________________________ Office Contact___________________________ Street Address _________________________________________________________________________Suite#_________ City ___________________________________ State ___________ Zip ________________ Tel______________________ License # _____________________ NPI # _____________________ DPS # ____________________ DEA #_____________

Bill to:

 Attorney

 PIP (Personal Injury Protection)

 Private Insurance

I hereby give American Specialty Pharmacy the authority to directly bill the aforementioned.

PRESCRIPTION

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

Rx

 Cyclobenzaprine  5mg  10mG

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY: _______ Refills_______

 Meloxicam  7.5mg  15mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY: _______ Refills_______

 Amitriptyline  25mg  50mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills________

 Ibuprofen 800mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills________

 Naproxen  375  500mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills______

 Tramadol 50mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills_______

 Ultracet 325/375mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills_______

 Gabapentin300mg400mg600mg SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills________

 Tizanidine  2mg  4mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills______

 Omeprazole 20mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills_______

 Ranitidine 150mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills________

 Prednisone 10mg

SIG:

4:4:3:3:2:2:1:1

 Medrol Dose Pack

SIG:

As Directed

 Methocarbamol  500mg  750mg SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills______

 Diclofenac Sodium 75mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills________

 Citalopram  20mg  40mg

SIG:

1

2

3

TAB

PO

QD

BID

TID QTY:_______ Refills_______

Prescriber’s Signature (signature required. NO STAMPS) ____________________________________________________ Date _____________ IMPORTANCE NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If you are not the named addressee, you should not disseminate, distribute, or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. Medicare and Medicaid or another state funded program will not cover above mentioned compounds. Co-payments due at dispensing of the medication

Fax completed form to (888) 966-0188

Visit us at WWW.AMERICANSPECIALTYPHARMACY.COM for online fillable forms.


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


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