Reclast Fax Referral Form PDF Details

Accessing effective treatment for conditions like postmenopausal osteoporosis and Paget’s disease of the bone requires seamless collaboration between healthcare providers. The Reclast Fax Referral Form facilitates this collaboration by streamlining the process of referring a patient for a Reclast infusion. Designed for efficiency, this form captures essential information: from the referring physician's details and the patient's medical and contact information to the specific diagnosis supported by lab results. Also, it outlines insurance details crucial for the treatment approval process. Equally important is the instruction for the infusion center or receiving doctor to update the referring physician once the infusion is administered, ensuring continuity of care. This form additionally serves as a conduit for the important safety information related to Reclast infusion, including contraindications and the necessity for calcium and vitamin D supplementation. By ensuring all pertinent data and safety considerations are communicated clearly, this form paves the way for a more coordinated, effective approach to treating these debilitating bone diseases.

QuestionAnswer
Form NameReclast Fax Referral Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesreclast fax referral form, infusion order form, novartis form, reclast benefit verification form

Form Preview Example

FAX REFERRAL FORM

5 mg/100 mL for infusion

Referring physicianÕs name:

Referring physicianÕs phone:

Referring physicianÕs fax:

Dear Doctor/Infusion Center:

I am referring my patient to you for a Reclast infusion.

J code:

J-3488

 

 

 

 

 

 

Patient name:

 

SS#

PATIENT

Patient address:

 

INFORMATION

 

 

 

 

[ w i t h p a t i e n t p e r m i s s i o n ]

Patient phone:

 

Date of birth:

/

/

 

 

 

 

 

 

 

 

Diagnosis:

Postmenopausal osteoporosis

 

 

PagetÕs disease of the bone

DIAGNOSIS

This patient has a calculated creatinine clearance of

 

> 35 mL/min and a normal serum calcium level.

Patient currently taking calcium and vitamin D supplements.

ICD-9 # ICD-9 #

Yes

Yes

733.01

731.0

Date of lab results:

No/ /

No

 

Primary Insurance:

 

 

 

Phone:

 

INSURANCE

Policy #

 

Group #

 

Policy holder:

 

 

 

 

 

 

 

Phone:

 

INFORMATION Secondary Insurance:

 

 

 

 

Policy #

 

Group #

 

Policy holder:

 

Attach copies of the following:

Lab results

 

Prescription

Insurance card(s), front and back

PhysicianÕs signature:

 

Date:

/

/

*A copy of this information can be given to the patient to bring to his or her appointment.

FAX BACK INFUSION CONFIRMATION

Please update the referring physician by faxing back this form.

Patient name:

 

Date of Infusion:

/

/

Infusing physician comments:

Important Safety Information

Reclast is contraindicated in patients with hypocalcemia or hypersensitivity to any component of this product. Reclast contains the same active ingredient found in Zometa¨ (zoledronic acid) Injection and patients receiving Zometa should not receive Reclast.

All patients should be instructed on the importance of calcium and vitamin D supplementation. Please refer to Reclast full Prescribing Information for recommendations.

Please see accompanying full Prescribing Information.

Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936

© 2008 Novartis

Printed in U.S.A. 1/08

RST-800185

How to Edit Reclast Fax Referral Form Online for Free

reclast fax referral form can be filled out online without difficulty. Just make use of FormsPal PDF editor to get the job done quickly. The tool is continually improved by our team, acquiring cool features and turning out to be more versatile. Starting is simple! All you have to do is adhere to the next easy steps directly below:

Step 1: Press the "Get Form" button above. It is going to open our pdf editor so that you can start filling in your form.

Step 2: Using this online PDF file editor, it's possible to do more than merely complete blank form fields. Express yourself and make your forms look sublime with customized textual content put in, or fine-tune the file's original input to perfection - all comes with an ability to insert stunning photos and sign the document off.

This document will require particular details to be filled in, thus ensure that you take some time to fill in what's asked:

1. Complete your reclast fax referral form with a number of essential fields. Gather all the important information and make certain there is nothing neglected!

Stage no. 1 in filling out novartis reclast fax referral form rst 800886 d

2. Right after filling in this part, head on to the subsequent stage and fill in the necessary particulars in all these blanks - Diagnosis, Postmenopausal osteoporosis, Pagets disease of the bone, ICD ICD, DIAGNOSIS, This patient has a calculated, mLmin and a normal serum calcium, Date of lab results, Patient currently taking calcium, INSURANCE INFORMATION, Primary Insurance, Policy, Secondary Insurance, Policy, and Attach copies of the following.

Part number 2 in filling out novartis reclast fax referral form rst 800886 d

3. This third step should also be fairly uncomplicated, Please update the referring, Patient name, Infusing physician comments, Date of Infusion, Important Safety Information, Novartis Pharmaceuticals, Novartis Printed in USA RST, and Please see accompanying full - each one of these form fields needs to be filled out here.

Step no. 3 in filling out novartis reclast fax referral form rst 800886 d

It's easy to make a mistake when filling in your Date of Infusion, consequently make sure you look again prior to when you finalize the form.

Step 3: When you have looked once more at the information you given, click "Done" to finalize your form at FormsPal. Sign up with FormsPal right now and immediately access reclast fax referral form, prepared for download. All modifications you make are preserved , helping you to edit the pdf later if needed. We do not share the details you provide when filling out forms at our website.

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