Blountspecialtypharmacy.com

ONCOLOGY PRESCRIPTION REFERRAL FORM
NEW PATIENT
CURRENT PATIENT
Patient Name _________________________________________________ SS#________________________ DOB __________ Height _________ Weight _________ Male Female Street Address _________________________________________________________ Apt # ____________ City ______________________________ State ___________ Zip ______________
Daytime Tel ____________________ Evening Tel ____________________ Cell _____________________ Email ________________________________________________________________
Ship to Patient at Home OR Patient will pick up at Physician Office Pharmacy ____Gill ST _____ West _____BMH Date Needed ___________________
Allergies _________________________________________________________________________ Comorbidities ______________________________________________________________________
Current Medications (if necessary, please fax a complete list) ___________________________________________________________________________________________________________
ICD-9 Diagnosis Code _____________________________ BSA ______________________________________ m2 Patient currently on therapy Yes No Date of next blood work __________________________ Biopsy Yes No Results ______________________________________________________________________________ Eligible for Medicare Yes No If yes, Medicare# Prescription Card Yes No If Yes, Carrier PRESCRIPTION
PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS
Afinitor
Votrient 200mg
Promethazine Compazine Emend Zofran Sancuso Transdermal Patch Other
Arimidex
Aromasin
Stivarga
Etoposide
Tamoxifen
Neupogen
Daily x days Every week BIW TIW Herceptin
Neulasta
Hycamtin
Matulane
Thalomid
Tykerb 250mg
Strength
By signing this form and utilizing our services, you are authorizing Blount and it’s employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies.
Prescriber’s Signature (signature required. NO STAMPS)
IMPORTANT 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. Please fax completed referral form to Blount Specialty at 865.238.9007
Visit us at WWW.BLOUNTSPECIALTYPHARMACY.COM for online fillable forms.

Source: http://www.blountspecialtypharmacy.com/forms/oncology_referral_form_final.pdf