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 PromethazineCompazine 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.
Prescription Program Formulary — To be used by members who have a formulary drug plan. Anthem Blue Cross and Blue Shield prescription drug benefits include medications available on the Anthem Drug List/Formulary. Our prescription drug benefits can • If you have additional offer potential savings when your physician prescribes medications on the drug list/formulary. questi