Phone: (877) 868-4110 Fax: (877) 868-4144

Prescribers and Staff

YOUR ONE-STOP SOLUTION

Our goal is to service all of the needs of your office and your patients.

• A member of our team will fax prescription and patient status updates throughout the prescription process• Prior authorizations to initiate treatment• Re-­Authorization to prevent therapy interruption• Cost management•• No cost for delivery to patient home or your office• Injection training for self injectable medications at patient home or in your office• Disease and treatment education prior to therapy initiation• Ongoing side effects management• Customize patient monitoring• Refill reminders and coordination•• Retail prescriptions to ensure patients have ONE PHARMACY• Infusion & Compounding services available

AMERICAN SPECIALTY PHARMACY is able to assist you. We are a SpecialtyPharmacy with retail stores with the ability to fill ALL of your patient’s medications.

Attached you will find a Prescription Referral Form for use with specific chronicillnesses. If your patients also need other medications not listed, just send the

prescription along with it and we’ll take care of that too!

For more information please call or email:

Phone: (877) 868-­4110 | Fax: (888) 294-­9434 | Email: info@americanspecialtypharmacy.com

PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX

www.AMERICANSPECIALTYPHARMACY.com

OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:

Compounded & Specialty MedicationsDurable Medical Equipment (DME)

Nutritional SupplementationWorkers’ Compensation Prescriptions

Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOUOur customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire

process. From contacting your insurance carrier to automatic re lls and overnight delivery.

We look forward to serving you and meeting all of your pharmacy needs.

www.AMERICANSPECIALTYPHARMACY.com

HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm

COMPLIMENTARY DELIVERYAll deliveries are delivered straight to

your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLSYour re lls are lled automatically based on

your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION2743 West 15th Street

Plano, TX 75075P: 877-868-4110 . F: 877-868-4144

EMAILinfo@americanspecialtyrx.com

At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe

and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or

unavailable medications to meet speci c patient needs.

We o er a full line of Professional Quality Vitamins, Nutritional Supplements, OTC Medications, Everyday

Prescriptions, Medical Equipment & Specialty Medications.

www.AMERICANSPECIALTYPHARMACY.com

PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟent demographiĐs)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________INSURANCE INFORMATION (Use this area or aƩĂĐŚ Đopy of insuranĐe Đard(s)

Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________

MEDICAL ASSESSMENT (Use this area or ĂƩĂĐŚ ƉĂƟent labs and other authorizaƟon informaƟon)

Primary Diagnosis: _________________________ ICD9 Code: ________________________ 696.1 PsoriasisSecondary Diagnosis: _______________________ ICD9 Code: ________________________ 696.0 PsorŝĂƟc ArthriƟs Previous Treatment(s): ________________________________________________ Date of Diagnosis: __________________ Previous Treatment Outcome:___________________________________________ Is ƉĂƟĞŶƚ taking Methotrexate? YES NO Has ƉĂƟent tried and failed oral systemic DMARD agents? YES NO Is ƉĂƟĞnt at risk for HepaƟƟƐ B? YES NO Has TB test been done? YES NO Results if YES: ________________________________________________________________ Is ƉĂƟĞŶƚ diagnosed with heart failure? YES NO Is ƉĂƟĞŶƚ diagnosed with lymphoma? YES NO

PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s) MEDICATION STRENGTH DIRECTIONS QNTY. REFILL

Prescriber Name: ________________________________________ NPI#: ______________________ Contact:__________________________________ Address:__________________________________ City: _________________ State: _________ ZIP: ____________ Ph: _________________________ Fax: ________________________________ DEA#: ________________________ St. License: ___________________________________ Email: ________________________________________________________________

ΎWƌĞƐĐƌiber Signature: _____________________________________________________ Date: _____________

Enbrel®

Humira®

50mg/ml Sureclick Autoinjector 50mg/ml PreĮůůed Syringe 25mg/0.5ml PreĮůůed Syringe 25mg Vial

50mg sub-q BIW (3-4 days apart) for 3 months then maintenance dose 50mg sub-q QW Other:

Psoriasis Starter Pack 40mg/0.8ml Pen 20mg/0.4ml PreĮůůed Syringe

80mg (2pens) sub-q day 1, then 40mg on day 8 then 40mg QOW 40mg sub-q QOW Other: _____________________________________

RemiĐade® 100mg Vial Infuse 5mg/kg at week 0, 2, 6 and every 8 weeks

Other: _____________________________________

Simponi® 50mg/0.5ml PreĮůůed SmartJect 50mg/0.5ml PreĮůůed Syringe

Inject 50mg/0.5ml sub-q once monthly Other: ___________________________________

Stelara®

45mg/0.5ml PreĮůůed Syringe 90mg/mL PreĮůled Syringe

<100kg: 45mg sub-q ŝŶŝƟĂƟŽn and 4 weeks followed by 45mg every 12weeks >100kg: 90mg sub-q ŝŶŝƟĂƟŽn and 4 weeks followed by 90mg every 12 weeks Other: ___________________________________

_____________

PRESCRIBER INFORMATION

RFDRMVS.12

PSORIASIS / DERMATOLOGYWƌĞƐĐƌŝƉƟŽŶ Form

Treating Patients Special

Ship to: PaƟent Home MD KĸĐe MD KĸĐe FIRST FILL ONLY

/ŶũĞĐƟŽŶdƌĂŝŶŝŶŐ DKĸĐĞAmerican Specialty to Arrange

FAX TO: (888) 294-9434

CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: info@americanspecialtyrx.com

Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

DERMATOLOGY / PSORIASISCOMPOUNDED PRESCRIPTION FORM

PRESCRIPTION

LJƐŝŐŶŝŶŐƚŚŝƐĨŽƌŵĂŶĚƵƟůŝnjŝŶŐŽƵƌƐĞƌǀŝĐĞƐLJŽƵĂƌĞĂƵƚŚŽƌŝnjŝŶŐŵĞƌŝĐĂŶĂŶĚŝƚ ƐĞŵƉůŽLJĞĞƐƚŽƐĞƌǀĞĂƐLJŽƵƌƉƌŝŽƌĂƵƚŚŽƌŝnjĂƟŽŶĚĞƐŝŐŶĂƚĞĚĂŐĞŶƚŝŶĚĞĂůŝŶŐǁŝƚŚŵĞĚŝĐĂůĂŶĚƉƌĞƐĐƌŝƉƟŽŶŝŶƐƵƌĂŶĐĞĐŽŵƉĂŶŝĞƐ

Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

&ĂdžĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzat 888-966-0188

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SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůLJϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůLJ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂnjĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽdžLJͲͲ'ůƵĐŽƐĞнϯйĐLJĐůŽǀŝƌYdz ϱϬŐŵ;&ŝŌLJ'ƌĂŵƐͿϳϱŐŵ;^ĞǀĞŶƚLJͲ&ŝǀĞ'ƌĂŵƐͿZĞĮůůƐͺͺͺͺͺϭ;ŽŶĞͿϮ;ƚǁŽͿϯ;ƚŚƌĞĞͿ

www.AMERICANSPECIALTYRX.com

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