MULTIPLE SCLEROSIS

MULTIPLE SCLEROSIS REFERRAL FORM Today's Date Anticipated Start Date
314 E 204th St., Bronx, NY 10467 April 29, 2024
Phone: 718-882-5614   Fax: 718-882-6365
Patient Name Date Of Birth Weight Gender
Street Address Apartment # City State Zip
Daytime Telephone Evening Telephone Cellphone Email Address
Ship To Patient At Date Needed
    OR Patient will pick up at  
ICD-9 CODE Diagnosis Allergies
Testing Results Patient Currently on Therapy Date of Next Blood Work
   
Insured's Name Relation to Patient Eligible for Medicare If yes, Medicare #
 
Prescription Card If Yes, Carrier Telephone Fax Number Policy/Group #
 
BIN # PCN # RXID # RX Group #
Prescriber's Name Office Contact
Street Address Suite # City State Zip
Telephone Fax Number Email Address
License # NPI # UPIN # DEA #
Prescription PLEASE ATTACH COPIES OF PATIENT'S INSURANCE CARDS
AVONEX ADMINISTRATION PACK 30mcg PreFilled
SIG
Inject 30mcg IM once weekly Other
QTY # of Weeks (1 pack = 4 week supply)
Refills X
BETASERON 0.3mg Vials
SIG
Inject SC every other day Other
QTY # of Weeks (1 box = 4 week supply)
Refills X
COPAXONE
40mg/ml Syringe
SIG
Inject 40mg SC three times weekly Other
20mg/ml Syringe
SIG
Inject 20mg SC once daily Other
QTY # of Syringes
Refills X
EXTAVIA VIALS
SIG
Inject SC every other day Other
QTY # of Weeks (1 box = 4 week supply) Refills X
REBIF TITRATION PACK 12 syringes
SIG
8.8mcg SQ TIW - weeks 1 & 2
Maintenance Dose following week 3 & 4		 22mcg SQ TIW - weeks 3 & 4
QTY # of Boxes (1 box = 4 week supply) Refills X
REBIF 22mcg/0.5ml
SIG 22mg (0.5ml) SQ TIW (48hrs apart)
QTY # of Boxes (1 box = 4 week supply) Refills X
REBIF 44mcg/0.5ml (Maintenance)
SIG Starting wk 5: 44mcg (0.5ml) SQ TIW (48hrs apart)
QTY # of Boxes (1 box = 4 week supply) Refills X
OTHER
SIG QTY Refills x
GILENYA
0.5 mg # orally once daily QTY - 28
Refills x

Prescriber's SignatureDate: April 29, 2024

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