Oncology Hematologic Cancer (A-J) (Bosulif ® , Farydak ® , Gleevec ® , Imbruvica ® , Jakafi ® ) Patient Information Prescriber + Shipping Information Patient name: ________________________ DOB: _____________ Sex: Female Male SSN: ______________________________ Language: ____________ Wt: _____ kg lbs Ht: _____cm in Address: _______________________________________________ Apt/Suite: _____ City: ________________ State: _____ Zip: ______ Phone: ___________________ Alternate: ____________________ Caregiver name: ____________________ Relation: _____________ Local pharmacy: _____________________ Phone: _____________ Insurance plan: _________________ Plan ID: ________________ Please fax a copy of front and back of the insurance card(s). Prescriber name: _______________________________________ NPI: ________________________________________________ Address: ______________________________________________ Apt/Suite: ______ City: ____________ State: _______ Zip: ______ Contact: ______________________________________________ Phone: _____________________ Alternate: _________________ Fax: _________________________________________________ Email: ________________________________________________ If shipping to prescriber: First Fill Always Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis (C00-D49): _____________________________________________________________ Diagnosis date: _________________ Patient Type (if applicable): Adult female NOT of reproductive potential Adult female of reproductive potential Adult male Date: _____________________ Child female NOT of reproductive potential Child female of reproductive potential Child male Authorization: _______________ Mutations: 17p deletion _______________ Lymph node size: _____ cm Absolute Lymphocyte count: _______/L TLS Risk: Low Moderate High Date: _________________ Prior Therapy Yes No Reason for Discontinuation of Therapy Approximate Start Date Approximate End Date ____________________________ ____________________________ ____________________________ ______________________________________ ______________________________________ ______________________________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Comorbidities: ___________________________________________________________________________________________________ Concomitant Medications: __________________________________________________________________________________________ Allergies: NKDA Other: _______________________________________________________________________________________ Prescription Quantity Refill Bosulif ® (bosutinib) Take 500 mg once daily by mouth with food ___________________________________________________________ 30 x 500 mg tablets __________________ ______ Farydak ® (panobinostat) Take 20 mg once daily by mouth on days 1, 3, 5, 8, 10 and 12 of a 21-day cycle ___________________________________________________________ 6 x 20 mg capsules ___________________ ______ Dexamethasone Take 20 mg once daily by mouth with food on days 1, 2, 4, 5, 8, 9, 11, and 12 of a 21-day cycle ___________________________________________________________________ 8 x 20 mg capsules ___________________ ______ Aspirin Take 81 mg once daily by mouth ___________________________________________________________________ 28 x 81 mg tablets ___________________ ______ Gleevec ® (imatinib) Take 400 mg once daily by mouth with a meal and full glass of water Take 600 mg once daily by mouth with a meal and full glass of water ___________________________________________________________ 30 x 400 mg tablets 30 x 400 mg tablets 60 x 100 mg tablets ___________________ ______ Imbruvica ® (ibrutinib) Take 420 mg once daily by mouth with a full glass of water Take 560 mg once daily by mouth with a full glass of water ___________________________________________________________ 90 x 140 mg capsules 120 x 140 mg capsules ___________________ ______ Jakafi ® (ruxolitinib) Take _______ mg once daily by mouth Take _______ mg twice daily by mouth 30 x ____ mg tablets 60 x ____ mg tablets ______ § Ninlaro ® , Pomalyst ® , Revlimid ® , Sprycel ® , Synribo ® , Tasigna ® , Thalomid ® , Venclexta™, Zolinza ® , and Zydelig ® are listed alphabetically on respective enrollment forms§ Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: ____________________________ Prescriber’s Signature:__________________________________________________________________________ Date: ______________ For patients requiring immune globulin therapy, please fill out the respective form: IVIg or SCIg. 225 Route 46 West Suite 3 Totowa, NJ 07512 Phone: 973-837-6877 Fax: 973-837-6878