Insurance Information (Please provide copy of insurance card front and ba ck) Primary Insurance _______________________________ ID#___________________________________ BIN#__________________PCN#__________________________ Phone ________________________________

Medication Delivery (Please Chose Only One) Patient Address First Fill Physician’s Of�ice, Re�ill to Patient Address Patient will pick up at Pharmacy

Diagnosis ( ICD -10 code) : Other Code: Description:

Patient Clinical Information: Allergies: Weight: lbs./kg Height:

in/cm

A�nitor

By signing this form and utilizing our services, you are authorizing SMP and its employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies.

__________/__________/____________Date

Today’s Date_________________________ Needed by______________________________ Patient Demographics (please provide or attach) Patient Name _________________________________________________________ Address _______________________________________________________________ City, State, Zip _________________________________________________________ Home Phone _______________________ Alt Phone ________________________ DOB __________________ Gender __________ Weight ____________BSA______m2

Prescriber (Please provide as much information as possible) Prescriber’s Name _____________________________ Group/Hospital _________________________ NPI ________________________ DEA ___________________ Specialty ____________________________ Address ____________________________________________________________________________________ City, State, Zip _____________________________________________________________________________ Phone _____________________________ Fax_________________________

2.5mg 5mg 7.5mg 10mg

Alecensa

150mg capsule

Alkeran

2mg tablet

Anagrelide

0.5mg capsule

Arimidex

1mg tablet

Aromasin 25 mg tablet

Casodex 50 mg tablet

CeeNu5mg 10mg 40mg

100mg tablets

Cyclophosphamide 50mg tablets25mg

Emcyt 140mg capsule

VePesid 50mg capsule

Fareston 60mg tablet

Farydak 10mg 15mg 20mg capsule

Femara 2.5mg tablet

Flutamide 125mg capsule

Gleevec 100mg 400mg tablets

Hexalen 50mg capsule

Hycamtin 0.25mg 1.0mg capsules

Hydrea 500mg capsules

Kisqali

Leucovorin 5mg 10mg 15mg 25mg tablet

Leukeran 2mg tablet

Lysodren

500mg tablet

Mekinist 0.5mg 2mg tablets

Purinethol 50mg tablet

Myleran 2mg tablet

Nilandron 150mg tablet

Ninlaro 2.3mg 3mg

4mg capsules

Odomzo 200mg capsule

Promacta 12.5mg 25mg 50mg

75mg tablets

Soltamox 10mg 3 ml oral solution

Sprycel 20mg 50mg 70mg 80mg 100mg 140mg tablets

Tabloid 40mg tablet

Ta�nlar 50mg 75mg capsules

Nolvadex 10mg 20mg tablets

Targretin 75mg capsule

Tasigna 150mg 200mg capsules

Temodar 5mg 20mg 100mg 140mg

180mg 250mg capsules

Vesanoid 10mg capsule

Trexall 5mg 7.5mg 10mg15mg tablets

Tykerb 250mg tablet

Venclexta 10mg 50mg 100mg tablets

Votrient 200mg tablet

Xeloda 150mg 500mg tablet

Xtandi 40mg capsule

Zolinza 100mg Capsule

Zykadia 150mg capsule

Medication Dose / Strength Directions Qty Ref.Medication Dose / Strength Directions Qty Ref.

Oncology Faxable

Breast Cancer

Hematologic Cancer

Lung Cancer

Melanoma & Basal Cell Cancer

Mekinist 0.5mg 2mg tablets

Ta�nlar 50mg 75mg capsules

Prostate & Renal Cell Cancer

A�nitor 2.5mg 5mg 7.5mg 10mg

Xtandi 40mg capsule

Other Cancers

A�nitor 2.5mg 5mg 7.5mg 10mg

Gleevec 100mg 400mg tablets

Fax: 855.447.6637Ph: 855.650.5009

Prescribers Signature

C50.919 Breast Cancer C65.9 Renal Cancer C61 Prostate Cancer C34.90 Lung CancerC56.9 Ovarian Cancer C95 Leukemia

Lovenox

Insurance Information (Please provide copy of insurance card front and ba ck) Primary Insurance _______________________________ ID#___________________________________ BIN#__________________PCN#__________________________ Phone ________________________________

Medication Delivery (Please Chose Only One) Patient Address First Fill Physician’s Of�ice, Re�ill to Patient Address Patient will pick up at Pharmacy

Diagnosis ( ICD -10 code) : Other Code: Description:

Patient Clinical Information: Allergies: Weight: lbs./kg Height:

in/cm

By signing this form and utilizing our services, you are authorizing SMP and its employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies.

Prescriber Signature

__________/__________/____________Date

Today’s Date_________________________ Needed by______________________________ Patient Demographics (please provide or attach) Patient Name _________________________________________________________ Address _______________________________________________________________ City, State, Zip _________________________________________________________ Home Phone _______________________ Alt Phone ________________________ DOB __________________ Gender __________ Weight ____________BSA______m2

Prescriber (Please provide as much information as possible) Prescriber’s Name _____________________________ Group/Hospital _________________________ NPI ________________________ DEA ___________________ Specialty ____________________________ Address ____________________________________________________________________________________ City, State, Zip _____________________________________________________________________________ Phone _____________________________ Fax_________________________

Oncology FaxableFax: 855.447.6637Ph: 855.650.5009

Prescribers Signature

C50.919 Breast Cancer C65.9 Renal Cancer C61 Prostate Cancer C34.90 Lung CancerC56.9 Ovarian Cancer C95 Leukemia

Support Medications

AspirinArixtraLovenoxCoumadin

Medication Dose / Strength Directions Qty Ref.

Aranesp Granix Neulasta NeupogenNplateProcritPromactaZarxio

ExjadeJadenu

Emend SancusoZofran

Sandostin LARSandostin Somatuline

Xermelo

Other Medications:

Other Medications: