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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


TRANSPLANT Form

Treating Patients Special

American Specialty to Arrange

Ship to:

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

PATIENT INFORMATION (Use this area or a ach

Pa ent Home

MD

e

nt demographics)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________ Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs.

INSURANCE INFORMATION (Use this area or

ch copy of insurance card(s)

Primary Name: _____________________________________ Phone: ___________________________________________ ID#: _______________________ Group: _______________

MEDICAL ASSESSMENT (Use this area or a ach

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

nt labs and other authoriz

n informa on)

Primary Dx: ______________________ ICD9 Code: ___________ Secondary Dx: ______________________ ICD9 Code: ___________ New Transplant? YES NO Transplant date: ___________________ Hospital Name: _____________________________________

PRESCRIPTION INFORMATION *(Use this area or a

ch copy of RX(s)

Cellcept

250mg 500mg 200mg/ml – 175mL/BO Other: ___________________

Myfo

180mg 360mg Other: ____________________

Prograf

0.5mg 1mg 5mg Other: _____________________

Qnty:

0.5mg 1mg 2mg 1mg/ml – 60mL/BO Other: _____________________

Qnty:

Rapamune Neoral

25mg 100mg 100mg/ml – 50mL/BO

Qnty:

Gengraf

25mg 100mg Other: ___________________

Sandimmune

0.5mg 1mg 5mg Other: ___________________

Valcyte

450mg Other: ___________________

Qnty:

Azithromycin

250mg 500mg Other: ___________________

Qnty:

Myclex

10mg Other: ___________________

Qnty:

___________

Dose:

*Prescriber Signature: ______________________________________________

Qnty: Re : Qnty: Re : Re :

Re : Re : Qnty: Re : Qnty: Re : Re : Re : Re : Qnty: Re :

Date: ___________________

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ O ce Contact: __________________________________________ TRNSPLTFRMVS.912


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

Transplant  

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