SHIP TO Patient Office

Kings Pharmacy 33 Park Avenue Newark, NJ 07104 Phone: 888-644-8633 Fax: 800-922-5150

Patient Name ___________________________________________ Date of Birth ____ /_____ /____ Sex: Male FemaleAddress _______________________________________________ City _____________ State _______ Zip _____________Home Phone ___________________ Alternate Phone ____________________ Social Security # ______________________

Prescriber’s Name _________________________________________ DEA # ___________________ NPI# ________________Address __________________________________________________ City _____________ State _______ Zip _____________Phone ______________________ Fax ________________________

Prescription Card Name of Insurer ____________________ ID# _________ BIN ________ PCN ________ Group ______Primary Insurance Subscriber ________________________ ID# _________ Is the Patient eligible for Medicare? Yes No

DATE _________________ NEEDS BY DATE _________________

Diagnosis Description __________________________ Other _______________________ Date of Diagnosis _________ OTHER CLINICAL INFORMATION/COMMENTS

Prior failed medications (medication and duration of treatment/reason for d/c): ______________________________________________ ___________________________________________________Is patient currently on RA therapy? Yes No Medications ____________________ TB/PPD test given? Yes NoBMD/T-score __________________________ Date ___________________ Does patient have a latex allergy? Yes NoIs Patient at risk for osteoporotic fracture as evident by any of the following? History of osteoporotic fracture Site: _____________________ Date: ____________________ Patient has tried and failed an oral bisphosphonate Patient has documented contraindication/is intolerant to oral bisphosphonate therapy(please submit a copy of DEXA w/prescription)

RHEUMATOID ARTHRITIS ENROLLMENT FORM

PATIENT INFORMATION (Complete the following or send patient demographic sheet)

PRESCRIBER INFORMATION

INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card)

STATEMENT OF MEDICAL NECESSITY (Please FAX recent clinical notes, Labs, Tests, with the prescription to expedite the Prior Authorization)

PRESCRIPTION INFORMATIONMEDICATION DOSE/STRENGTH SIG. QTY.

Please enroll my patient into the following manufacturer support program: ________________________________I hereby freely and voluntarily have selected Kings Pharmacy to dispense the medication herin prescribed by my physician.Patient Signature: ________________________________________________PHYSICAN’S SIGNATURE

PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is con�dental, privilideged proprietary or exempt from disclosure under applicable law. If this is receieved by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to 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 addresse.

Humira®

_______________________________________________ ___________________________________________________

40mg/0.8ml Pen 40mg/0.8ml Prefilled Syringe Inject 40mg SC every OTHER weekInject 40mg SC ONCE a week

4-week supply

4-week supply50mg/ml SureClick™ Autoinjector 50mg/ml Prefilled Syringe25mg Prefilled Syringe

Inject 50mg SC ONCE a weekInject 25mg TWICE a weekOther:

100mg/0.67ml PFS (28 syringes) 100mcg SC dailyOther:

125mg/ml Prefilled Syringe (4 syringes) Inject 125mg SC ONCE weeklyVials

50mg/0.5ml Prefilled Syringe50mg/0.5ml Autoinjector Inject 50mg ONCE a month

4-week supply60mg Prefilled Syringe

Synvisc®

Supartz® 25mgInject 25 mg per 2.5 mL INTRA-ARTICULARLY into the knee once weekly for a total of 5 injection

Other

Enbrel®

Kineret®

Orencia®

Simponi®

Prolia®

______________________________________________REFILLS