TREATMENT REQUEST FORM CHEMOTHERAPEUTIC AGENTS

Phone: (877) 370-2845Fax: (888) 992-2809

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Today’s Date _____________________________Patient Name:_____________________________ Address:__________________________________ City:___________ State:______ Zip:___________ Cell:__________________ Work:______________ Date of Birth: ____________ Sex: □ M □ F Allergies: _________________________________Place of service: ___________________________

Physician Name:____________________________TIN: ______________________________________DEA : _____________________________________Name of Practice:___________________________Address:__________________________________ City:_____________ State:______ Zip:_________ Phone: ___________________________________Fax:______________________________________Offi ce Contact:_____________________________

Date of Next Treatment: Patient’s Current Height:

Patient’s Current Weight: (lbs/kgs)

Medical History

Primary Dx: (ICD-9) (Description) Current Stage of Cancer:

Secondary Dx: (ICD-9) (Description) Estimated Duration of Therapy:

This is For:

□ New Diagnosis and Treatment □ Continuation of Treatment

Intent to Treat:

□ Adjuvant □ Curative □ Palliative

Select from the following commonly used medications:*Please include all medications to be used in the patient’s therapy

Drug Name JCODE Dose Quantity Directions (include route and frequency) Refi lls

Supportive Medications□ Aloxi (palonosetron HCL 25mcg) J2469

□ Dexamethasone (1 mg) J1100

□ Diphenhydramine (50 mg) J1200

□ Granisetron (100 mcg) J1626

□ Zofran (ondansetron HCL 1mg) J2405

□ Other:

□ Other:

Chemotherapy (Please list the chemotherapy regimen below and attach any applicable labs)□ Abraxane (paclitaxel protein-bound 1mg) J9264

□ Adriamycin (doxorubicin HCL 10mg) J9000

□ Adrucil (fl uorouracil 500mg / 5-FU) J9190

□ Alimta (pemetrexed 10mg) J9305

□ Avastin (bevacizumab 10mg) J9035/C9257

□ Doxil (doxorubicin, liposomal 10mg) Q2050

□ Erbitux (cetuximab 10mg) J9055

□ Faslodex (fulvestrant INJ 25mg) J9395

□ Gemzar (gemcitabine HCL 200mg) J9201

□ Herceptin (trastuzumab 10mg) J9355

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□ Hycamtin (topotecan 0.1 mg) J9351

□ Kadcyla (ado-trastuzumab emtansine 1 mg) J9354

□ Kyprolis (carfilzomib 1mg) J9047

□ Lupron (leuprolide acetate 7.5mg) J9217

□ Perjeta (pertuzumab 1 mg) J9306

□ Provenge (sipuleucel-T auto CD54+) Q2043

□ Rituxan (rituximab 100mg) J9310

□ Sandostatin LAR (octreotide 1mg) J2353

□ Taxol (paclitaxel injection 30 mg) J9265

□ Vectibix (panitumumab INJ 10 mg) J9303

□ Velcade (bortezomib 0.1mg) J9041

□ Vidaza (azacitidine INJ 1mg) J9025

□ Xgeva/Denosumab 1mg J0897

□ Yervoy (ipilimumab 1mg) J9228

□ Zaltrap (ziv-aflibercept 1 mg) J9400

□ Zometa (zoledronic acid INJ 1mg) J3489

□ Other:

□ Other:

Growth Factor Medications (CMS Guideline Applies – MUST attach recent HgB/HcT lab values)□ Aranesp (darbepoetin alfa 1mcg) J0881

□ Neulasta (pegfilgrastim 6mg) J2505

□ Neupogen (filgrastim G-CSF 1mcg) J1442

□ Procrit (epoetin alfa 1000 units) J0885

□ Other:

□ Other:

Immune Globulins□ Carimune, Panglobulin NF, GammgardSD (immune globulin, powder 500mg)

J1566

□ Flebogamma (500mg) J1572

□ Gammagard liq. Inj. (500mg) J1569

□ Gammaplex (500mg) J1557

□ Gamunex-C (500mg) J1561

□ Immune globulin (liquid, intravenous, NOS 500mg)

J1599

□ Octagam (500mg) J1568

□ Privigen (500mg) J1459

□ Other:

□ Other:

□ Unless indicated, Generic Substitution Allowed*Please include all medications to be used in the patient’s therapy

Physician’s Signature (On File)___________________________ (Physician signature required to validate prescriptions)

This form must be completed in its entirety, as it may be forwarded to the Health Plan for authorization. This facsimile transmission is intended to be delivered to the named addressee and may contain information that is confidential, privileged, and 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/or telephone number set forth herein and obtain instructions as to the 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.