HIV/AIDS Prescription Order Form Deliver to: Patient’s Home
Prescriber’s Office
To ePrescribe send prescription to: Phone: 800.540.4700 Fax: 800-540-3400
Other: _______________ 340B Eligible: Yes
410 Cloverleaf Drive Baldwin Park, CA 91706
No
PATIENT INFORMATION
PRESCRIBER INFORMATION
Last Name: ______________________________________________
Prescriber Name: _________________________________________
First Name: ______________________________________________
MD DO NP PA
SSN: _______________________ Date of Birth: _________________
Practice Name: ___________________________________________
Gender: M F Height: _________ Weight: ________ lbs kg
Address: _______________________________________________
Allergies: ________________________________________________
City: _________________________ State: _________ Zip: ________
Best Phone: _______________ Alternate Phone: ________________
License #: _________ NPI: ______________ DEA#: ______________
Home Address: ___________________________________________
Phone: ______________________ Fax: _______________________
City: _______________________ State: _________ Zip: __________
Contact Name: ____________________ Phone: ________________
Emergency Contact: _______________________________________
Collaborating Physician: ___________________________________
INSURANCE INFORMATION: PLEASE FAX COPY OF FRONT AND BACK OF INSURANCE CARD DIAGNOSIS AND CLINICAL INFORMATION: PLEASE FORWARD A LIST OF CURRENT MEDICATIONS Naïve to treatment Experienced to treatment B20 HIV/AIDS Z20.6 PEP Lab Values B18.1 Hepatitis B R64 Cachexia (HIV Wasting) Lab Baseline Current B18.2 Hepatitis C CD4/T-Cell Count Z20.6 PrEP Other: ____________________ HIV/RNA PRESCRIPTION INFORMATION Medication Directions Single Tablet Regimens
QTY
ATRIPLA BIKTARVY COMPLERA DELSTRIGO DOVATO GENVOYA JULUCA ODEFSEY STRIBILD SYMFI SYMFI LO SYMTUZA TRIUMEQ
Medication
Directions Protease Inhibitors
QTY
Refill
EVOTAZ KALETRA NORVIR PREZCOBIX PREZISTA REYATAZ
NNRTIs or Non-Nukes EDURANT INTELENCE PIFELTRO SUSTIVA VIRAMUNE
Entry / Attachment Inhibitor NRTIs or Nukes
CIMDUO DESCOVY EMTRIVA EPIVIR EPZICOM TEMIXYS TRUVADA VIREAD ZIAGEN TRUVADA TYBOST
Refill
SELZENTRY TROGARZO
Integrase Inhibitor ISENTRESS TIVICAY
Other Other
PrEP PK Enhancer
PRESCRIBER SIGNATURE: PLEASE SIGN AND DATE BELOW
Prescriber Signature – Substitution Permissible
Date
Prescriber Signature – Dispense as Written
Date
I authorize Premier Pharmacy Services to act as my representative and on behalf of myself and my patient to initiate any authorization processes from applicable health plans, if needed, including submission of any necessary forms to such health plans.
