Nexplanon Cvs Form – Fill Out and Use This PDF

Patient Information

Last Name:

First Name:

MI:

DOB:

SSN:

Address:

City:

State:

Zip Code:

Phone:

Alternative Phone:

Primary Language:

Patient

Insurance

Information

Copy and attach front and back of insurance card and prescription drug card

Prescription Drug Card:

Medical Insurance:

Phone:

BIN:

Phone:

PCN:

Policy #:

Group #:

Policy #:

Group #:

Policy Holder Information (If diferent from patient)

Name:

Name:

Employer:

SS#:

Employer:

SS#:

Relation to Patient:

Relation to Patient:

Patient has no insurance and/or does not want insurance billed. Requests Self Pay option: q Single payment

q 3-month payment plan

Patient Authorization

(For beneit investigation request only)

I understand that in order for Caremark L.L.C. and Schering Corp. (hereafter “Merck”), a subsidiary of Merck & Co., Inc. to provide me with assistance, they will need to obtain, review, use and disclose my personal health information (PHI), including information relating to my medical condition and information on my request form, and any prescription. I authorize my physician, pharmacy(ies) and my health plan(s) to disclose my PHI to Caremark L.L.C. and their administrators as necessary to complete the insurance investigation process. I further authorize Caremark L.L.C. and their administrators to use my PHI to provide services through this program, and to disclose the information to my health plan(s), and their contractors for the purpose of coordination of beneits, reimbursement support, investigating insurance coverage and to coordinate the delivery, receipt and storage of my IMPLANON or NEXPLANON prescription medication for the sole purpose of administration by my prescribing provider. The prescribing provider listed below is my healthcare agent who administers IMPLANON or NEXPLANON at his/her medical facility.

I agree to allow Caremark L.L.C. to contact me via mail, telephone, or email in connection with carrying out these services. I understand that my name, address, and any other personal identifying information provided in my request form will be available to Caremark L.L.C. , and their ailiates. I understand that my PHI disclosed under this request may no longer be protected by privacy laws and may be re-disclosed by Caremark L.L.C. only for the purposes described herein. I also understand that non-identiiable information concerning individuals requesting assistance with insurance coverage may be summarized for statistical or other purposes and provided to Merck by Caremark L.L.C., but my identity will not be determinable from such summary information.

I understand that if I don’t provide an Authorization, I will not be able to obtain service program assistance provided by Caremark, L.L.C. on behalf of Merck. I understand that I may cancel this Authorization at any time by mailing a written request for such cancellation to my prescribing physician, pharmacy, health plans and Caremark L.L.C., and the cancellation will not apply to any information already used or disclosed pursuant to this Authorization.

If I don’t cancel this Authorization, the Authorization will expire 15 months from the date signed below. Merck has retained Caremark L.L.C. to provide services to customers, including reimbursement services. Information and questions related to the information provided in regard to this request should be referred directly to Caremark L.L.C. Merck personnel are not aware of patient speciic reimbursement information and are not permitted to discuss such information with customers. I have read this document or have had it explained to me. I understand that I may request a copy of this Authorization once it has been signed.

Prescriber Information

(IMPLANON OR

NEXPLANON

-trained clinician)

Prescriber Name (First, Last):

Title: q MD

q DO q NP q PA

Name of Practice:

Oice Contact:

Phone:

Fax:

Address:

City:

State:

Zip Code:

Email:

State Medical License #:

Expiration Date:

NPI #:

Contact Preference: q Phone

q Fax q Email

For ARNP, NP & PA, collaborative physician agreement is with:

Date:

Prescriber Information

(IMPLANON OR NEXPLANON- trained clinician)

Buy and Bill Order Form	IMPLANON®	NEXPLANON®
Phone: 866-318-3492 Fax: 866-769-3882	(etonogestrel implant)68 mg	(etonogestrel implant)

Purchase of IMPLANON and/or NEXPLANON (Buy and Bill)

Prescriber Name (First, Last):

Title: q MD

q DO q NP q PA

Name of Practice:

Oice Contact:

Phone:

Fax:

Address:

City:

State:

Zip Code:

Email:

State Medical License #:

Expiration Date:

NPI #:

Contact Preference: q Phone

q Fax q Email

For ARNP, NP & PA, collaborative physician agreement is with:

Date:

Shipping Information

Ship to: q Prescriber’s Address Above

q Address Below

Requested Delivery Date:

Prescriber, Institution or Practice Name:

Address:

City:

State:

Zip Code:

Phone Number:

Contact Name:

CVS Caremark will invoice Purchaser at the time of each shipment. Payment to CVS Caremark for the products is due and payable within ninety (90) days after the date of CVS Caremark’s related invoice (“Payment Due Date”). Purchaser must sign a letter of agreement prior to irst shipment.

Buy & Bill

(Prescriber purchases, billed to the prescriber)

Physician, Institution or Practice Name:

HIN:

Address:

City:

State:

Zip Code:

Phone Number:

Contact Name:

Quantity Requested:

PRODUCT: IMPLANON

NDC: 00052-0272-01 Purchase Order # (if required by practice or institution):

Quantity Requested:

PRODUCT: NEXPLANON

NDC: 00052-0274-01

Credit Card: Name on Card:

Account #:

Exp. Date:

Form of Business: q Hospital

q Private Practice q PHS (340B) q Sub PHS (340B Prime Vendor)

q FSS (DoD, VA, IHS)

q Planned Parenthood q Other (please specify):

Tax Identiication Number: FEIN:

SSN:

Submit copy of tax exempt certiicate if eligible

(IF FEIN NOT AVAILABLE)

Provider will be invoiced for all products [IMPLANON or NEXPLANON] purchased from Caremark, L.L.C. at the rates quoted at the point-of-sale. Provider is inancially responsible for, and agrees to pay, Caremark, L.L.C. all invoiced charges for products ordered by Provider. Each invoice will be due and payable by Provider within the payment terms ofered by Caremark, L.L.C. on the date-of-order.

Signature:		Print Name and Title:			Date:
If diferent from signature, provide the name of the IMPLANON and/or NEXPLANON trained clinician responsible for this order:

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2

3

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1Patient Beneit Veriication

NOTE: Please notify your patients that CVS Caremark will attempt to reach them by phone to verify their acceptance of the product if there is a inancial responsibility due.

PATIENT INFORMATION: Please provide complete contact information for the patient.

PATIENT AUTHORIZATION: Please have patient read, sign and date.

PRESCRIBER: The prescriber listed on the form must be trained in the insertion and removal of IMPLANON if prescribing IMPLANON, or NEXPLANON, if prescribing NEXPLANON.

2Prescription Information

NOTE: To order IMPLANON and/or NEXPLANON by prescription for a participating patient, please complete the prescription section, in addition to patient information, patient insurance information, and prescriber information sections.

PRESCRIBER SIGNATURE: The individual signing this form must be the trained clinician who will be inserting IMPLANON and/or NEXPLANON.

NOTE: If your patient will be paying by cash, you may use this form as a prescription. Please check the box of either single payment or 3 month payment plan under the “Insurance Information”portion of this form.

Product will ship without patient contact if the patient has zero inancial responsibility.

3Shipping Information

NOTE: It is important that all shipping information be completed prior to submitting this form. If you have a requested delivery date, please indicate in the space provided.

4Buy and Bill Purchase

NOTE: To purchase IMPLANON and/or NEXPLANON for Buy and Bill, complete this section. This will allow IMPLANON Direct to ensure that IMPLANON and/or NEXPLANON is received on time. Purchaser must sign a letter of agreement with CVS Caremark prior to irst shipment.

SIGNATURE AUTHORIZATION: Buy and Bill purchases must be authorized by an individual with purchasing authority.

If this person is not trained on the product purchased, please identify the trained clinician responsible for the order.

Before submitting,

remember to....

qIndicate product requested

qIndicate services requested

qFill in the patient’s information, including Social Security Number; have patient sign

qMake sure the prescriber listed on the form is trained in inserting IMPLANON and/or

NEXPLANON

qAccurately and thoroughly complete the Insurance Information section, including all corresponding codes

qFax the completed form along with both sides of the patient’s insurance card

qTo contact IMPLANON Direct with any questions or concerns, please call 866-318-3492

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5Faxing the Form

Please fax the completed form, along with both sides of the patient’s insurance card and prescription drug card, to

866-769-3882.

IMPLANON and NEXPLANON are registered trademarks of N.V. Organon, a subsidiary of Merck & Co., Inc.

Copyright © 2011 Caremark, L.L.C.

WOMN-1012193-0000 09/11

IMPLANON®

(etonogestrel implant)68 mg

NEXPLANON®

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