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					                                                                                                       Cystic Fibrosis
                                                                                                      Enrollment Form
                Fax Referral To: 800-323-2445
                        Phone: 800-237-2767                                        Date:                              Needs by Date:
  Ship to:            Patient             Office             Other:
                       PATIENT INFORMATION                                                                                                         PRESCRIBER INFORMATION
       (Complete the following or send patient demographic sheet)                                                Prescriber’s Name:
      Patient Name:                                                                                                 State License #:                                                         UPIN:
            Address:                                                                                                         DEA #:                                                          NPI #:
     City, State, Zip:                                                                                           Group or Hospital:
       Home Phone:                                                                                                          Address:
    Alternate Phone:                                                                                                 City, State Zip:
                SS #:                Primary Language:                                                                        Phone:                                                        Fax:
       Date of Birth:                       Gender:                                                                 Contact Person:                                                                 Phone:
                                          INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card)
       Prescription Card:             Name of Insurer:                                             ID#:                               BIN:                              PCN:                           Group:
      Primary Insurance:                  Subscriber:                                              ID#:                               Name of Insurer:                                                 Phone:
  Secondary Insurance:                        Subscriber:                                          ID#:                               Name of Insurer:                                                 Phone:
                                                                                 STATEMENT OF MEDICAL NECESSITY
  Diagnosis:                                      Pertinant Medical History/Other Conditions:
      277.0 Cystic Fibrosis                        Other Conditions:   Pancreatic Insufficiency     CFRD                              Osteoporosis       Liver Disease         Depression
                                                                        Pregnancy (Due Date: ______)                                   Other:
                                                   Blood Glucose test result (if >14 y/o):                                               Fasting      Non-Fasting
                                                   Most recent PFT%:                                                       Is Pseudomonas aeruginosa present in airway cultures?      Yes                                 No
                                                   Allergies:                                                              Height:            Weight:              Date of Measurement:
   Date of Diagnosis:                             Concomitant Medications:
                                                                                         PRESCRIPTION INFORMATION
                                                                                                          Specialty Medications
           MEDICATION                                     STRENGTH                                                              DIRECTIONS                                                         QUANTITY                  REFILLS
  *        Colistimethate
              Colistimethate Kit – This complimentary kit (contains sterile water for injection, syringes, needles, & sharps container) will be included as needed with dispensing.
  *   Hyper-Sal                         7%
  *   Pulmozyme                        2.5mg
  *   TOBI                            300mg
  ***Pari LC nebulizer: tubing recommended one tube per inhaled treatment –                                             Quantity:                                Replace tubing every 6 months?                          Yes          No

                                                                                    Nebulizers
        Pari LC Plus                                              Use as directed with compressor.
              Replace tubing every 6 months (Manufacturer and CF Foundation recommendation)


        CVS Caremark/CarePlus to facilitate nebulizer instruction via phone or in-person at local CarePlus CVS/pharmacy.
                                                                                                          Pancreatic Enzymes
                                                      Creon 5
         Creon                                       Creon 10
                                                      Creon 20
                                                      Pancreaze 4
                                                      Pancreaze 10
        Pancreaze                                    Pancreaze 16
                                                      Pancreaze 20
                                                      Zenpep 5
        Zenpep                                       Zenpep 10
       (pancrelipase)                                 Zenpep 15
                                                      Zenpep 20

                                                                                                   Other Routine CF Medications




  Ancillary Supplies and Kits Provided As Needed for Administration
       X                                                                                                                       X
        PRODUCT SUBSTITUTION PERMITTED                                                                 (Date)                  DISPENSE AS WRITTEN                                                                               (Date)
IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is
received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should
such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Rare Disorders CF 013111

				
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