RHEUMATOID ARTHRITIS INFLAMMATION PRESCRIPTION FORM

RHEUMATOID ARTHRITIS & INFLAMMATION PRESCRIPTION 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
ICD-10 CODE			PPD (TB Test)	Chest X-ray	Date of Labs
MO6.9 Rheumatoid Arthritis L40.59 Psoriatic Arthritis M45.9 Ankylosing Spondylitis
Rheumatoid Factor + Total Swollen Joints		Previously treated	If yes, what drugs		Other
		Yes No	Corticosteroids Methotrexate Humira Enbrel

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

CIMZIA (certolizumab pegol)
Initial Dose: 400mg (two 200mg subcutaneous injections) at weeks 0, 2 & 4 (Starter Kit #6) Qty 1 Kit
Maintenance Dose: 200mg subcutaneous injection every other week QTY 28 Day Supply
Other		Refill x

ENBREL (etanercept)
Dose:	Prefilled Syringe 25mg 50mg	Multiuse Vial 25mg	SureClick 50mg
Dispense:	1 x week 2 x week Qty 28 Day Supply

HUMIRA (adalimumab)
Dose:	40mg/0.8mL PFS 40mg/0.8mL Pens 40mg20mg/0.4mL PFS.
Patient weight (kg)		Qty 28 Day Supply	Refill x
Dispense:	Inject 40mg subcutaneously every other week
Juvenile Arthritis Patient weight 15kg to < 30kg inject 20mg subcutaneously every other week Patient weight > 30kg inject 40mg subcutaneously every other week
Qty 28 Day Supply		Refill x

PROLIA (osteoporosis 733.01)
PRE-MEDICATIONS Administer APAP 500 – 1000mg PO and Benadryl 25mg PO prn
RX --- PROLIA (DENOSUMAB) 60MG ONCE EVERY SIX MONTHS Qty #1

SIMPONI (golimumab) inject 50mg subcutaneously once per month
Dose:	SureJect 50mg/0.5mL \| Prefilled Syringe 50mg/0.5mL QTY: 1
SIMPONI ARIA	50 mg/4 mL (12.5 mg/mL) in a single use vial QTY: 1
SIG: 2 mg/kg intravenous infusion over 30 minutes at weeks 0 and 4, then every 8 weeks

FORTEO (#1 pen)	Inject 20mg SQ Daily Qty 1pen w/30 needles
PEN NEEDLES	31 gauge-6mm use with forteo as directed QTY: #30
KINERET (anakinra)	Inject 100mg subcutaneously daily
ORENCIA	Inject 125mg subcutaneously weekly QTY: #30
ORENCIA	250mg Vial (IV use only) Loading Dose: 10mg/kg IV x 1 dose, then 125mg SC weekly, start within 24hrs of IV dose, 1 dose, 4 week supply

XELJANZ (tofacitinib citrate) 5mg tablet
SIG		QTY		Refills

ACTEMRA (tocilizumab) Prefilled-Syringe
QTY		Refills
Inject 162mg subcutaneously every other week (pt wt < 100kg)
Inject 162mg subcutaneously every week (pt wt > 100kg or per clinical response)
ACTEMRA IV	mg Q4W (every 4 weeks) Adult (IV) Dosage
starting dose is 4 mg per kg every 4 weeks followed by an increase to 8 mg per kg every 4 weeks based on clinical response

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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