Kidney / nephrologist

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: [email protected]

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.


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

[email protected]

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.


PATIENT INFORMATION (Use this area or ĂƩĂĐŚ ƉĂƟĞnt 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 ĂƩĂĐŚ Đopy of insuranĐĞ Đard(s)

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

MEDICAL ASSESSMENT (Use this area or ĂƩĂĐh paƟent labs and other authorizĂƟŽŶ ŝŶĨŽƌŵĂƟŽŶͿ

Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________

PRESCRIPTION INFORMATION *(Use this area or ĂƩĂĐŚ Đopy of RX(s)

Prescriber Name: _____________________________________________ NPI#: ____________________________________

Address: _________________________________ City: __________________________ State: _________ Zip: _________

Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________

HIVFRMVS.12

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PRESCRIBER INFORMATION

Treating Patients SpecialShip to: PaƟent Home MD KĸĐe

/ŶũĞĐƟŽŶ�dƌĂŝŶŝŶŐ͗ D��KĸĐĞ��American Specialty to Arrange

FAX TO: (888) 294-9434

CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]

Pick up at ASP

Anemia Aranesp ® (darpopoetin alfa) Epogen ® (epoetin alfa) Procrit® (epoetin alfa)

SIG: Inject dose ____________ mcg/kg or _____________mcg

Route: IV SC Frequency _______________________

Dispense quanƟƚǇ��ͺ____________ ReĮůls _______________

Neutropenia

Rx: Leukine® (sargramosƟn) (liquid) 500 mcg/ml

(lyophilized) 250 mcg 500 mcg

Neulasta® (pegfilgrastim) 6 mg/0.6 ml prefilled Syringe

Neupogen® (filgrastim) 300 mcg/ml vial 300mcg/0.5 prefilled Syringe

480 mcg/ml vial 480mcg/0.8 prefilled Syringe

SIG: Inject Dose: ____________ mcg/kg or _____________mcg/m2

Route: IV SC Continuous SC

Dosing Directions(Include daily, weekly, cyclic, one-time, duration of txt. etc.)

_____________________________________________________________________

_____________________________________________________________________

Dispense Quantity: _____________ Refills:_______________

Supplies (if needed per dose): 1 ml syringe 3 ml syringe

22G 1” mixing needle Sterile Water 10 ml271/2G 5/8”admin. needle (Pediatrics Only)

PhenylketonuriaKuvanDose: 10mg/kg Other: _____ mg/kgbody weight

η�ŽĨ��ĂǇƐ͗��ͺͺͺͺͺͺ� ZĞĮůůƐ͗�ͺͺͺͺͺͺ

�ŝƌĞĐƟŽŶƐ͗��ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

WĂƌŽǆǇƐŵĂů�EŽĐƚƵƌŶĂů�,ĞŵŽŐůŽďŝŶƵƌŝĂSoliris ™ 300mg/30mlSig: _________________________________________________YƚǇ͗�ͺͺͺͺͺͺͺͺ� ZĞĮůů͗�ͺͺͺͺͺͺ

Renvela 800mg TabSensipar 30 60 90

Sig: _________________________________________________YƚǇ͗�ͺͺͺͺͺͺͺͺ� ZĞĮůů͗�ͺͺͺͺͺͺ

7G 5/8” needle 25G 5/8” needle

Kd,�Z

NOTES: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PATIENT INFORMATION (Use this area or aƩach ƉĂƟĞnt demographics)

Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs.

INSURANCE INFORMATION (Use this area or ĂƩĂch copy of insurance card(s)

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

MEDICAL ASSESSMENT (Use this area or aƩach ƉĂƟĞnt labs and other authorizĂƟŽn informaƟon)

Primary Dx: ______________________ ICD9 Code: ___________ Secondary Dx: ______________________ ICD9 Code: ___________New Transplant? YES NO Transplant date: ___________________ Hospital Name: _____________________________________

PRESCRIPTION INFORMATION *(Use this area or aƩĂch copy of RX(s)

*Prescriber Signature: ______________________________________________ Date: ___________________

Cellcept

MyfoƌƟĐ

250mg 500mg 200mg/ml – 175mL/BO Other: ___________________

�ŝƌĞĐƟŽŶƐ͗ Qnty:

ReĮůů:

180mg 360mg Other: ____________________

Rapamune

TRNSPLTFRMVS.912

TRANSPLANTWƌĞƐĐƌŝƉƟŽŶ Form

Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oĸce Contact: __________________________________________

Prograf

Neoral 25mg 100mg 100mg/ml – 50mL/BO

�ŝƌĞĐƟŽŶƐ͗ReĮůů:

Qnty:

�ŝƌĞĐƟŽŶƐ͗ ReĮůů:

Qnty:

ReĮůů:

Qnty:

Gengraf 25mg 100mg Other: ___________________

�ŝƌĞĐƟŽŶƐ͗

ReĮůů:Qnty:

Sandimmune 0.5mg 1mg 5mg Other: ___________________

�ŝƌĞĐƟŽŶƐ͗ReĮůů:Qnty:

Valcyte 450mg Other: ___________________

�ŝƌĞĐƟŽŶƐ͗ Qnty:

ReĮůů:

0.5mg 1mg 5mg Other: _____________________

0.5mg 1mg 2mg 1mg/ml – 60mL/BO Other: _____________________


ReĮůů:

Qnty:


Azithromycin 250mg 500mg Other: ___________________


ReĮůů:

Qnty:

Myclex 10mg Other: ___________________


ReĮůů:

Qnty:

___________ Dose: �ŝƌĞĐƟŽŶƐ͗

ReĮůů:

Qnty:

Treating Patients Special CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]

Ship to: PaƟent Home MD KĸĐe

/ŶũĞĐƟŽŶ�dƌĂŝŶŝŶŐ͗ D��KĸĐĞ��American Specialty to Arrange

Kidney / nephrologist

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