PSORIASIS REFERRAL FORM

PSORIASIS REFERRAL FORM		Today's Date
314 E 204th St., Bronx, NY 10467		April 29, 2024
Phone: 718-882-5614 Fax: 718-882-6365		New Patient Current Patient

Patient Name			Date Of Birth	Weight	Gender
					Male Female
Street Address		Apartment #	City	State	Zip

Daytime Telephone	Evening Telephone	Cellphone	Email Address

Ship To Patient At				Date Needed
Home Work OR Patient will pick up at Physical Office Pharmacy
Diagnosis			Location		Allergies
L40.8 Psoriasis L40.59 Psoriatic Arthritis			Scalp Groin Nails
Severity			Patient currently on therapy?	PPD Test	Results
Mild (<3% BSA) Moderate (3-10% BSA) Severe (>10% BSA)			Yes No	Yes No

Insured's Name		Relation to Patient	Eligible for Medicare	If yes, Medicare #
			Yes No
Prescription Card	If Yes, Carrier	Telephone	Fax Number	Policy/Group #
Yes No
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

OTEZLA
Titration Starter Pack	SIG: Take as directed	QTY 55 for 28 days
Maintenance: 30 mg	SIG: Take 30mg twice a day	QTY 60
Refills

ENBREL 50 mg/ml not to be used in pediatric weighing less than 63 kg (138 lbs)
SureClick (prefilled autoinjector) PFS (prefilled syringes)
Starting Dose	50 mg SQ BIW (72-96 hours apart) QTY 8
*Psoriasis: The recommended starting adult dose is for 3 months(Maximum of 2 refills), please specify number of refills
Maintenance Dose	50 mg SQ weekly QTY 4

ENBREL 25 mg/ml not to be used in pediatric weighing less than 31 kg (68 lbs)
25 mg/0.5 ml PFS (Prefilled Syringes)	25 mg Multiple-Use
Vial 25 mg SQ BIW (72-96 hours apart) QTY 8

STELARA Starting Dose:		45mg	90mg SQ BIW initially & weeks 4 later
Maintenace Dose:		45mg	90mg SQ every 12 weeks

REMICADE 100 mg vial		MD Office Infusion		Home Infusion
Infusion supplies needed			Yes No
Starting Dose	5 mg/kg	# mg on week 0, week 2 & week 6 then
Maintenance Dose	5 mg/kg	# mg every 8 weeks for		# infusions every 8 weeks
Other		QTY		Refills

HUMIRA
Starting Dose:	Inject two 40 mg pens/syringes SQ on day 1, then one 40mg on day 8, then one 40mg every other week QTY 4 NO REFILLS
Maintenance Dose:	40 mg SQ every other week QTY 2

SIMPONI(*Only for PSA)

50mg/0.5ml SmartJect (Autoinjector)

Inject 1 single-use Autoinjector SC once monthly QTY # 1

50mg/0.5mL Prefilled Syringe

Inject 1 single-use Prefilled Syringe SC once monthly QTY # 1

Prescriber's SignatureDate: April 29, 2024

IMPORTANT NOTICE: This form is intentded to be delivered only to the named addressee. It contains material that is confidential, privilaeged, 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.

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