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Complete this form for patients who have received at least three courses of IV-infliximab

Patient Information

First Name *

Last Name *

Date of Birth *

Gender *

Home Phone

Cell Phone

Email *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Emergency Contact

Emergency Phone

Complete this form for patients who have received at least three courses of IV-infliximab

Insurance Information

Primary Insurance

ID #

Group #

Secondary Insurance

ID #

Group #

Prescription Card ID

Bin #

PCN #

Group #

Complete this form for patients who have received at least three courses of IV-infliximab

Prescriber Information

Prescriber Name

DEA #

NPI #

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Fax

Contact Person

Complete this form for patients who have received at least three courses of IV-infliximab

Clinical Information

Patient Weight

Unitkglbs

Patient Height

Unitcmin

Allergies

TB/PPD TestPositiveNegative

Date Read

Hepatitis B ScreenPositiveNegative

Date Read

Diagnosis

Diagnosis *ICD-10: K50 (Moderately to severely active Crohn's Disease following treatment with an infliximab product administered intravenously)ICD-10: K51 (Moderately to severely active Ulcerative Colitis following treatment with an infliximab product administered intravenously)Other

Other Diagnosis

Complete this form for patients who have received at least three courses of IV-infliximab

Prescription Information

Medication

ZYMFENTRA®
(infliximab-dyyb)

Dose and Directions *120mg/mL solution in a single dose pre-filled pen. Inject SC every 2 weeks120mg/mL solution in a pre-filled syringe with needle shield. Inject SC every 2 weeks

Quantity#2 (1 month)#6 (3 months)

# of Refills

Complete this form for patients who have received at least three courses of IV-infliximab

Prescriber Signature Required (stamp signature not allowed)

By signing this form and using this pharmacy's services, you are authorizing this pharmacy to serve as your prior authorization designated agent in dealing with prescriptions and medical insurance companies.

SubstitutionsMay Substitute / Product Selection Permitted / Substitution PermissibleDispense As Written / Brand Medically Necessary / Do Not Substitute / No Substitution / May Not Substitute

CA, MA, NC & PR: Interchange is mandated unless Prescriber writes the words "No Substitution"

NY & Iowa providers, please submit electronic prescription.

Prescriber Signature *

Date

The information contained in this facsimile may be confidential and is intended solely for the use of the named recipient(s). Access, copying or re-use of the facsimile or any information contained therein by any other person is not authorized. If you are not the intended recipient, please notify us immediately by faxing back to the originator.

Zymfentra® Enrollment Form

Patient Information