YOUR DEDICATED RESOURCE FOR ASSISTANCE with MYALEPT (metreleptin) for injection THE BYMYSIDE PROGRAM CAN HELP YOU GET STARTED ON MYALEPT
|
|
- Phillip Thompson
- 5 years ago
- Views:
Transcription
1 by side Support Access Resources YOUR DEDICATED RESOURCE FOR ASSISTANCE with MYALEPT (metreleptin) for injection Introducing the BYMYSIDE Patient Support Program. Through the BYMYSIDE Program, you will work with a dedicated team made up of registered nurses, trained pharmacists, and a MYALEPT case manager. Call the toll-free BYMYSIDE support line at , from 8 am to 8 pm (ET), Monday through Friday, to speak with a member of the BYMYSIDE team. THE BYMYSIDE PROGRAM CAN HELP YOU GET STARTED ON MYALEPT A BYMYSIDE team member is available to answer questions you may have about getting started on MYALEPT. From access and affordability support to preparation and administration training, we re here for you every step of the way. A BYMYSIDE team member can walk you through the benefits offered by the BYMYSIDE Program. ACCESS AND AFFORDABILITY OPTIONS SUPPORT FOR MYALEPT PREPARATION AND ADMINISTRATION SPECIALTY PHARMACY OFFERINGS
2 YOUR ACCESS AND AFFORDABILITY OPTIONS The BYMYSIDE Program aims to make MYALEPT (metreleptin) for injection accessible and affordable for patients. A BYMYSIDE case manager will work with you to navigate assistance programs and access options. Help for patients who have insurance If you have insurance, a BYMYSIDE team member can help you better understand your benefits. Help for patients who cannot afford their out-of-pocket costs, and patients who don t have insurance If you have insurance but cannot afford the out-of-pocket costs for MYALEPT, or if you are a patient without insurance, a BYMYSIDE team member can research alternative forms of funding and reimbursement, and explain all of your options. There is a savings program available to help eligible patients cover a portion of your out-of-pocket costs for MYALEPT You may also be eligible to receive assistance from other sources such as independent charitable foundations LEARN MORE Visit myaleptbymyside.com or call , from 8 am to 8 pm (ET), Monday through Friday, to speak with a member of the BYMYSIDE team. 2
3 YOUR PREPARATION AND ADMINISTRATION SUPPORT Your healthcare provider will show you how to inject MYALEPT before you use it for the first time. A healthcare provider should also watch you inject your MYALEPT dose the first time you inject it. Do not inject MYALEPT until your healthcare provider has shown you the right way to inject it. If you have questions or do not understand the instructions, talk to your healthcare provider or pharmacist. To help with this, the BYMYSIDE Program offers an optional In-Home Nursing Injection Support Program at no cost to you. Through this program, in addition to the training your healthcare provider provides, a registered home health nurse can come to your home to help supervise the preparation and administration of your first dose of MYALEPT. Talk to your healthcare provider or a BYMYSIDE team member about any questions you may have regarding preparation, administration, and storage of MYALEPT. Registered home health nurse MYALEPT administration assistance and supervision Step-by-step training on MYALEPT reconstitution and administration BENEFITS OFFERED MYALEPT resources including the Prescribing Information, Medication Guide, and Instructions for Use Helpful tips for staying on treatment and maintaining a regular dosing schedule 3
4 SUPPORT THROUGH A SPECIALTY PHARMACY MYALEPT (metreleptin) for injection is not available from retail pharmacies; it is dispensed only by a specialty pharmacy. This means that you cannot pick up your MYALEPT prescription from your local retail pharmacy it will be shipped directly to you or to your healthcare provider s office. At Aegerion, the BYMYSIDE team works with a specialty pharmacy to provide you with a full range of support. Specialty pharmacy offerings: Medication and supplies shipments Refill assistance, reminder calls, and check-ins Assistance with medication replacement 24/7 pharmacist and nurse support Ensure you receive your MYALEPT and supplies Please see the steps on the following page to learn how the BYMYSIDE team completes and fulfills your MYALEPT prescription. LEARN MORE Visit myaleptbymyside.com or call , from 8 am to 8 pm (ET), Monday through Friday, to speak with a member of the BYMYSIDE team. 4
5 HOW THE BYMYSIDE TEAM FILLS YOUR PRESCRIPTION STEP 1 Your healthcare provider writes you a prescription for MYALEPT and faxes it to the BYMYSIDE Patient Support Program. STEP 2 A member of the BYMYSIDE team will contact you from a phone number you might not recognize to complete and fulfill your prescription for MYALEPT. STEP 3 A member of the BYMYSIDE team will work with you to Navigate your access and affordability options Eligible patients may receive reimbursement assistance; talk with a member of the BYMYSIDE team for eligibility requirements Coordinate your medication and supplies shipments from the specialty pharmacy STEP 4 The specialty pharmacy will ship your medication and supplies directly to you or to your healthcare provider s office. 5
6 APPROVED USE MYALEPT (metreleptin) for injection is a prescription medicine used with a healthcare provider-recommended diet to treat problems of leptin deficiency (lack of leptin) in people with congenital or acquired generalized lipodystrophy. It is not known if MYALEPT is safe and effective to treat problems caused by partial lipodystrophy or to treat liver disease, including non-alcoholic steatohepatitis (NASH). MYALEPT should not be used to treat people with HIV-related lipodystrophy or people with metabolic disease, including diabetes and high triglycerides, without signs or symptoms of congenital or acquired generalized lipodystrophy. IMPORTANT SAFETY INFORMATION MYALEPT may cause serious side effects, including: risk for loss of natural leptin activity or loss of MYALEPT efficacy due to neutralizing antibodies. Some people who use MYALEPT make antibodies in their blood that may reduce how well the leptin in their body (endogenous) works or how well MYALEPT works. Side effects may include infection, problems with blood sugar (including diabetes), or an increase in the amount of fat in your blood (triglycerides) increased risk of lymphoma (a type of blood cancer) MYALEPT is only available through a restricted program called the MYALEPT Risk Evaluation and Mitigation Strategy (REMS) Program. For more information about the MYALEPT REMS Program go to or call Do not use MYALEPT if you have general obesity not caused by a congenital leptin deficiency or are allergic to metreleptin or any of the ingredients in MYALEPT. Before using MYALEPT, tell your healthcare provider if you have any medical conditions including if you: have or have had problems with your blood cells, including low blood cell counts (especially your white blood cells), bone marrow, immune system, pancreas, swollen lymph nodes, lymphoma, high blood triglyceride levels, or use insulin or a sulfonylurea are pregnant or plan to become pregnant as it is unknown if MYALEPT will harm your unborn baby. If you become pregnant while using MYALEPT, talk to your healthcare provider about registering with a program to collect information about the outcomes of moms and babies exposed to MYALEPT during pregnancy. You can enroll in the MYALEPT program by calling are nursing or plan to nurse. You should not nurse while you take MYALEPT 6
7 Tell your healthcare provider about all the medicines you take, including prescription and overthe-counter medicines, vitamins, and herbal supplements. Take MYALEPT exactly as your healthcare provider instructs you. For newborns and infants, mix MYALEPT with sterile water for injection (preservative-free) (WFI). MYALEPT contains benzyl alcohol when mixed with a liquid called bacteriostatic water for injection (BWFI). Serious side effects including death have happened in newborns or infants who have received the preservative benzyl alcohol. Low blood sugar (hypoglycemia) can occur when MYALEPT is used with medicines that can cause hypoglycemia, such as insulin or sulfonylurea. Your insulin or sulfonylurea dose may need to be lowered while you use MYALEPT. Signs and symptoms of low blood sugar may include shakiness, sweating, headache, drowsiness, weakness, dizziness, confusion, irritability, hunger, fast heart beat, and/or feeling jittery. Talk to your doctor about the symptoms and treatment for hypoglycemia. Worsening symptoms of autoimmune disease may occur in people who have or have had certain problems with their immune system. Talk to your doctor about what symptoms you should watch for that may require further testing. Allergic reactions (hypersensitivity), including serious allergic reactions, can happen in people who use MYALEPT. Call your healthcare provider right away if you have any signs or symptoms of an allergic reaction including swelling of the face, lips, tongue or throat; problems breathing or swallowing; rash; itching (hives); fainting or feeling dizzy; or very rapid heartbeat. The most common side effects of MYALEPT include headache, low blood sugar (hypoglycemia), decreased weight, and/or abdominal pain. Talk to your healthcare provider about any side effect that bothers you or that does not go away. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit or call FDA
8 by side Support Access Patient Support Program Resources YOUR DEDICATED RESOURCE FOR ASSISTANCE with MYALEPT (metreleptin) for injection The BYMYSIDE team is here to help. A member of the BYMYSIDE team will Work with you to navigate MYALEPT access and affordability options In addition to the training provided by your doctor, provide you with support for MYALEPT preparation and administration Coordinate your MYALEPT shipment with the specialty pharmacy LEARN MORE Visit myaleptbymyside.com or call , from 8 am to 8 pm (ET), Monday through Friday, to speak with a member of the BYMYSIDE team Aegerion Pharmaceuticals, Inc. MYALEPT is a registered trademark and BYMYSIDE is a trademark of Aegerion Pharmaceuticals, Inc. All rights reserved. MYA/US/053 9/15.
Save up to $4,000 a year?!
Save up to $4,000 a year?! Indication and Usage HYQVIA [Immune Globulin Infusion 10% (Human) with Recombinant Human Hyaluronidase] is an immune globulin with a recombinant human hyaluronidase indicated
More informationGetting Started on. (iloprost) Inhalation Solution VENTAVIS
Getting Started on VENTAVIS (iloprost) Inhalation Solution Please see accompanying full Prescribing Information and Patient Information, and Important Safety Information on the back. Starting on VENTAVIS
More informationCoordinating Access to Obtain ZOLINZA
ACT Now: 1-866-363-6379 Coordinating Access to Obtain ZOLINZA Reimbursement Support Services Patient Assistance BEFORE YOU LEAVE, please have your physician s office fax your prescription for ZOLINZA and
More informationTREATMENT JOURNAL. Helping you stay on track SELECT IMPORTANT SAFETY INFORMATION
TREATMENT JOURNAL Helping you stay on track Acthar is a prescription medicine for the reduction of proteinuria in people with nephrotic syndrome of the idiopathic type (unknown origin) without uremia (accumulation
More informationDate of Birth: Phone: ( ) Gender: M F. City: State: Zip:
To apply for help in affording your Seebri Neohaler (glycopyrrolate) Inhalation Powder prescription, please mail completed application to: Sunovion Support Prescription Assistance Program ( Program ) PO
More informationAbiraterone Acetate (Zytiga )
Abiraterone Acetate (Zytiga ) ( a-bir-a-ter-one AS-e-tate ) How drug is given: By mouth Purpose: To stop the growth of cancer cells in prostate cancer How to take this drug 1. Take this medication on an
More informationName: Date of Birth: Phone: ( ) Gender: Mailing Address: City: State: Zip: Social Security Number:
To apply for help in affording your Sunovion prescription, please mail or fax a completed application to: Sunovion Support Prescription Assistance Program ( Program ) PO Box 220285, Charlotte, NC 28222-0285
More informationWelcome to OPEN DOORS
Welcome to OPEN DOORS A support program for IPF patients taking OFEV (nintedanib) capsules For more information, call OPEN DOORS at 1-866-OPENDOOR (1-866-673-6366), or visit www.ofev.com IPF=idiopathic
More informationYOUR GUIDE TO PATIENT SUPPORT
YOUR GUIDE TO PATIENT SUPPORT H.P. Acthar Gel (repository corticotropin injection) is indicated for the reduction of proteinuria in people with nephrotic syndrome of the idiopathic type (unknown origin)
More informationPO Box , Charlotte, NC Phone: (877) Fax: (877)
To apply for help in affording your prescription for Latuda (lurasidone HCl) tablets, please mail or fax a completed application to Sunovion Support Prescription Assistance Program ( Program ), PO Box
More informationEMPOWERING YOU a guide for caregivers. Tom D. EMPLICITI caregiver I ll always provide help, love, and support
EMPOWERING YOU a guide for caregivers Tom D. EMPLICITI caregiver I ll always provide help, love, and support Denise N. EMPLICITI caregiver Letting him know how much he s loved caring for a loved one is
More informationPatient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country
Hoover Hearing Clinic A division of Hoover ENT Hoover, Alabama 35244 205-733-9694 Tel PATIENT INFORMATION ACCOUNT # DATE MD NEW UPDATE Patient s Full Name DOB Age Patient s SSN Sex: Male Female Preferred
More informationThank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need. Did you know that NeedyMeds has thousands of other free resources?
More informationHARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES
HARRISON COUNTY SCHOOLS OFFICE OF HEALTH SERVICES 445 W. Main Street Clarksburg, WV 26301 (304) 326-7690 FAX (304) 326-7691 Dear Parent, Date Please complete the enclosed forms and return them to your
More informationCobimetinib (Cotellic ) ( koe-bi-me-ti-nib )
Cobimetinib (Cotellic ) ( koe-bi-me-ti-nib ) How drug is given: by mouth Purpose: to stop the growth of melanoma cancer cells How to take this drug 1. This drug can be taken with or without food. 2. Swallow
More informationSEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE. Student Name: Current Date: Date of Birth: Grade:
SEVERE ALLERGIC REACTION MANAGEMENT PROCEDURE QUESTIONAIRE Student Name: Current Date: Date of Birth: Grade: 1. Describe in detail what your child is allergic to: 2. How often does your child have a severe
More informationIPSEN CARES Enrollment Form
Questions? Call IPSEN CARES at 1-866-435-5677 IPSEN CARES Enrollment Form Please print the form, fill it out completely, sign it, and FAX TO 1-888-525-2416 PATIENT q All IPSEN CARES Program Services q
More informationMedication Administration Skill Checklist (to be accompanied by daily medication log for applicable students) 1 page
See the following pages for exhibits relating to medical treatment: Exhibit A: Exhibit B: Exhibit C: Exhibit D: Exhibit E: Medication Administration Request Form and Guidelines for Administration of Medication
More information2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care
2200 Northern Boulevard, Suite 133 East Hills, NY 11548 855-670-6077 Fax (516) 918-9039 Transitional Care Dear New Patient: We welcome you to our practice as a transitional patient. We will be managing
More informationPage 17. Medication Management Policy and Practice Guidelines
Page 17 APPENDIX A Medication Management Policy and Practice Guidelines Index Scope Definition of medication Principles underpinning safe use of medications Procedure Guidelines Scope 1. Medication packaging
More informationA B O U T M E A B O U T M E. I n t h i s s e c t i o n, y o u w i l l f i n d : Your important contacts. Your medical history
A B O U T M E A B O U T M E I n t h i s s e c t i o n, y o u w i l l f i n d : Your important contacts Your medical history A place to list your medications A place to write down your questions A calendar
More informationDate of Birth: Phone: ( ) Gender: M F. City: State: ZIP:
To apply for help in affording your LATUDA (lurasidone HCI) prescription, please see Important Safety Information, including Boxed Warning on pages 4 and 5 and enclosed full Prescribing Information. Please
More informationColumbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician
Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR 97031 541-387-6125 fax 541-387-6315 Physician Welcome to the Columbia Gorge Heart Clinic. We welcome you as a patient and
More informationPATIENT INFORMATION SHEET:
PATIENT INFORMATION SHEET: LAST NAME: FIRST NAME/MI: ADDRESS: CITY: STATE: ZIP CODE: SOCIAL SECURITY #: HOME: CELL: WORK: SEX: M F BIRTHDATE: MARITAL STATUS: SINGLE MARRIED WIDOWED OTHER EMPLOYER NAME:
More informationFood / Insect Allergy Action Plan
Food / Insect Allergy Action Plan 2017-2018 Student s Name: of Birth: Teacher Allergy to: Asthmatic: Yes* No Grade *Higher risk for severe reaction Step 1: Treatment Symptoms Give Checked Medication**
More informationPAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!
PATIENT INFORMATION FORM PATIENT DATA: - - PATIENT NAME (LAST, FIRST, MIDDLE) SOCIAL SECURITY # SEX ( ) - ( ) - ADDRESS HOME PHONE NUMBER MOBILE PHONE NUMBER CITY STATE ZIP CODE OCCUPATION / / DATE OF
More informationCare of Boarders/Day Pupils who are sick (Day and Boarding)
Adams Grammar School Care of Boarders/Day Pupils who are sick (Day and Boarding) Monitoring Frame of engagement Date Member of Staff Responsible MW-S October 29 th 2013 Governor Accountability Consultation
More informationPatient Registration. City, State & Zip Code Date of Birth Age. Occupation: Family Physician: Married Single Other Spouse's Name
*SHAREDID-42* Date of Birth: Page 1 of 2 Patient Registration Account # Patient Name Home Telephone # Work Telephone # Social Security Number Cell Telephone # Address Patient Sex City, State & Zip Code
More informationDirectly Observed Therapy for Active TB Disease and Latent TB Infection
Directly Observed Therapy for Active TB Disease and Latent TB Infection Policy Number TB-5001 Effective Date (original issue) September 6, 1995 Revision Date (most recent) June 26, 2008 Subject Matter
More informationEtoposide (VePesid ) ( e-toe-poe-side )
Etoposide (VePesid ) ( e-toe-poe-side ) How drug is given: by mouth Purpose: to stop the growth of cancer cells in ovarian cancer, small cell lung cancer, Hodgkin disease, and other cancers How to take
More informationNEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES
NEBO SCHOOL DISTRICT BOARD OF EDUCATION POLICIES AND PROCEDURES J - Students Administering Medication to Students JHCD DATED: August 8, 2018 SECTION: POLICY TITLE: FILE NO.: TABLE OF CONTENTS 1. PURPOSE
More informationIf you have an. invasive fungal infection. Why did I get it? What is it? What should I do? What can I expect? INFORMATION FOR YOU AND YOUR FAMILY
INFORMATION FOR YOU AND YOUR FAMILY my UNDERSTANDING invasive fungal infection If you have an invasive fungal infection What is it? Why did I get it? What can I expect? What should I do? Inside this brochure
More information2.. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours.
STUDENTS August 30, 2012 STUDENTS Health Services Allergic Reactions When a student s physician prescribes emergency allergy injections and related medication (Epinephrine, EpiPen, EpiPen Jr.), and there
More informationWhat to Expect If you need care
What to Expect If you need care in the United States Online Consumer Portal Backed by the power of UnitedHealth Group, the largest single carrier in the United States, UnitedHealthcare Global is committed
More informationVIEKIRA PAK and VIEKIRA PAK-RBV *
VIEKIRA PAK and VIEKIRA PAK-RBV * *ribavirin ABB0017 Patient Booklet.indd 1 Contents Getting started with VIEKIRA PAK or VIEKIRA PAK-RBV 1 Frequently asked questions about treatment 8 Other frequently
More informationRequest for Severe Allergy Information
Request for Severe Allergy Information Dear Parent, You have disclosed that your child has a severe allergy. Wylie ISD requires additional information in order to take necessary precautions for your Child
More informationPARTICIPANT HANDBOOK. City and County of San Francisco Department of Public Health Updated February 2017
PARTICIPANT HANDBOOK City and County of San Francisco Department of Public Health Updated February 2017 www.healthysanfrancisco.org Contents About this Handbook...1 What is Healthy San Francisco?...1 Your
More informationPOLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS
POLICY TITLE: Administering Medications POLICY NO: 561 PAGE 1 of 5 MEDICATIONS The Board of Trustees of the Mountain Home School District recognizes that students attending the schools in this district
More informationCalifornia Enrollment Guide
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions California 1 100 Enrollment Guide Your Aetna plan features, and how to enroll Plans effective January 1, 2016
More informationIPSEN CARES Enrollment Form
Questions? Call IPSEN CARES at 1-866-435-5677 IPSEN CARES Enrollment Form Please print the form, fill it out completely, sign it, and FAX TO 1-888-525-2416 q All IPSEN CARES Program Services q HCP Injection
More informationMy Patient Passport. Patient Name
My Patient Passport Patient Name Use this passport to record and organize your healthcare journey. It is a tool to help with communication between you and your healthcare provider. Patient and Family Engagement
More informationKaiser Permanente (No. and So. California) 2018 Union
Kaiser Permanente (No. and So. California) General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage Precertification Requirements Precertification Penalty Health Savings
More informationDear Parent/Guardian:
Dear Parent/Guardian: If it is necessary for your child to receive Epinephrine during school hours, school health policy requires that you provide a written request for the administration of the prescribed
More informationTo All Mission Ranch Primary Care Patients:
To All Mission Ranch Primary Care Patients: At Mission Ranch Primary Care we strive to provide the best possible customer service. As a part of this, we ask that you fill out this paperwork and return
More informationRULES AND REGULATIONS PERTAINING TO THE USE OF LATEX GLOVES BY HEALTH CARE WORKERS, IN LICENSED HEALTH CARE FACILITIES, AND
RULES AND REGULATIONS PERTAINING TO THE USE OF LATEX GLOVES BY HEALTH CARE WORKERS, IN LICENSED HEALTH CARE FACILITIES, AND BY OTHER PERSONS, FIRMS, OR CORPORATIONS LICENSED OR REGISTERED BY THE DEPARTMENT
More informationTo be completed by healthcare provider
Allergy and Anaphylaxis Action Plan and Medication Orders Student s Name: D.O.B. Grade: School: Teacher: ALLERGY TO: Place child s photo here To be completed by healthcare provider History: Asthma: YES
More informationParagon Infusion Centers Patient Information
Paragon Infusion Centers Patient Information Please complete the following form as accurately as you are able. Inaccurate and/or incomplete information can delay our ability to authorize your treatments,
More informationAn EPO Employee and Retiree Medical Plan...
An EPO Employee and Retiree Medical Plan... Member Handbook...with PPO Benefit Option The benefits and service you love. Plus. IMPORTANT CONTACT INFORMATION PLAN INFORMATION AND MEMBER SERVICES Office
More informationLast Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone
Last Name First Middle Mailing Address City State Zip Phone Date of Birth Age Soc. Sec# Cell Employer Work Phone Email Address Emergency contact Phone # Relation: Name of Primary Insurance Policy # -----
More informationOgden City School District Allergy Health and Emergency Care Plan for School. School: Grade: School Year:
PARENTS: Please place student s picture here Ogden City School District Allergy Health and Emergency Care Plan for School Student Name: Student must avoid contact with known allergen. School staff must
More informationPATIENT REGISTRATION FORM
Natalie A. Nealeigh, PA-C PATIENT REGISTRATION FORM PATIENT INFORMATION (PLEASE PRINT) Last Name: First Name: MI: Street Address: City: State: Zip: Home #: Cell #: Work #: DOB: Age: Sex (M/F): Marital
More informationTALK. Health. The right dose. May is Mental Health Month. 4 tips for people who use antidepressants
VOLTEE PARA ESPAÑOL! SPRING 2016 Health THE KEY TO A GOOD LIFE TALK IS A GREAT PLAN May is Mental Health Month. Everyone deserves good mental health. Whether you have a minor mental health condition that
More informationHealth Home Flow Hypothetical Patient Scenario
Health Home Flow Hypothetical Patient Scenario Client Background: Soozie SoonerCare Soozie is a single female, age 42, 5'6" tall 215 pounds. She smokes 2 packs of cigarettes a day. At age 24, Soozie was
More informationPediatric New Patient Form
Pediatric New Patient Form Internal Medicine & Pediatrics Patient Information Today's Date: Legal Name: Gender: M / F Date of Birth: Age: Race : Ethnicity: E-mail Address: Other: Home Address: Primary
More informationHarvoni for the treatment of Hepatitis C
Harvoni for the treatment of Hepatitis C Department of Hepatology Digestive Diseases Centre Patient Information This leaflet is designed to give you important information about your new medicine. It is
More informationHampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms
Newport News Public Schools Hampton Roads Regional Schools Life-Threatening Allergy Management Protocol Forms Developed by the Hampton Roads School Nurse Managers Parents/Guardians: Please complete Life
More informationYour annual preventive visit, or complete physical exam, is scheduled with. Dr. on at AM/PM.
Dear: Your annual preventive visit, or complete physical exam, is scheduled with Dr. on at AM/PM. Please bring the following with you on the date of your appointment: A list of your current medication(s),
More information2018 Plan Year State Employees Prescription Drug Plan
2018 Plan Year State Employees Prescription Drug Plan Welcome to CVS Caremark We manage your prescription benefits like your health insurance company manages your medical benefits. That means helping you
More informationADMINISTRATION OF MEDICATION BY DELEGATION
ADMINISTRATION OF MEDICATION BY DELEGATION ROLE AND RESPONSIBILITY OF THE TEACHER TRAINING MANUAL Medication Training Manual Final 10-2-17 Page 1 of 17 MEDICATION ADMINISTRATION TRAINING OBJECTIVES UPON
More informationWITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you
PATIENT REGISTRATION FORM PLEASE PRINT : Referring Physician: Primary Care: Patient s Name: Last First: M.I. Address: City: State: Zip: Home Phone: Cell: Work: Email: Preferred Contact Method Race: Ethnicity:
More informationAbbvie 3D for the treatment of Hepatitis C Genotype 1
Abbvie 3D for the treatment of Hepatitis C Genotype 1 Department of Hepatology Digestive Diseases Centre Patient Information This leaflet is designed to give you important information about your new medicine.
More informationFAQ S. Frequently Asked Questions: WellCare Clinic Logistics
Frequently Asked Questions: FAQ S WellCare Clinic Logistics 1. What is the City of Lawrence WellCare Clinic? The City of Lawrence WellCare Clinic is a part of the CHAMP Wellness Program. The WellCare Clinic
More informationPATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Age: Address : Social Security #: City: Sex: Marital Status: State: Zip: Language: Pt Declines Home Phone#: Race: Pt Declines Work Phone#:
More informationNeedyMeds
NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
More informationPatient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 + RITUXIMAB
Patient identifier/label: Page 1 of 6 FORM CHOP 21 + RITUXIMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital
More informationTRINITY DENTAL CLINIC Medical History Form Date:
Page 1of 4 TRINITY DENTAL CLINIC Medical History Form Date: NAME DATE OF BIRTH ADDRESS CITY STATE ZIP PHONE NUMBERS PHYSICIAN DO WE HAVE PERMISSION TO LEAVE A MESSAGE AT THE PHONE NUMBERS LISTED ABOVE?
More informationPLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: 516-354-8597 ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT. THANK YOU - 1 - NEW PATIENT MEDICAL INFORMATION Steven J.
More informationWelcome to the Southeastern Urology Associates meridianemr Patient Portal
New Patients: Please register for our Portal following the instructions below and send us a Message though the New Message Message for Office Section to let us know you received this packet and are confirming
More informationMedication Therapy Management
Medication Therapy Management Presented by Sylvia Saade, PharmD Ghada Khoury, Pharm D, BCACP Objectives Describe the components of medication therapy management (MTM) programs Discuss the needs of MTM
More informationCNA SEPSIS EDUCATION 2017
CNA SEPSIS EDUCATION 2017 WHAT CAUSES SEPSIS? Sepsis occurs when the body has a severe immune response to an infection Anyone who has an infection is at risk for developing sepsis Sepsis occurs when the
More informationUW MEDICINE PATIENT EDUCATION. Angiography: Percutaneous or Transjugular Liver Biopsy. How to prepare and what to expect. What is a liver biopsy?
UW MEDICINE PATIENT EDUCATION Angiography: Percutaneous or Transjugular Liver Biopsy How to prepare and what to expect This handout explains how to prepare and what to expect when having a percutaneous
More informationPLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )
PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE DATE: (MR: ) Office Use Only PATIENT S NAME: (FIRST, MIDDLE INITIAL, LAST) DATE OF BIRTH AGE SOCIAL SECURITY # MALE/FEMALE ADDRESS
More informationSTUDENTS Any school employee authorized in writing by the school administrator or school principal:
Fremont School District No. 215 STUDENTS 3510 Student Medicines Assistance in Self Administration of Medicines to Students Any school employee authorized in writing by the school administrator or school
More informationPlease bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION. Cell Phone ( ) Employer s Name
Please bring your ID and Medical/Dental Insurance cards to all appointments PATIENT REGISTRATION PATIENT INFORMATION Name Last First M.I. Social Security. Home Address Street City State Zip Mailing Address
More information2. Short term prescription medication and drugs (administered for less than two weeks):
Medication Administration Procedure This is a companion document with Policy # 516 Student Medication To access the policy: click on Policies (under the District Information heading) The Licensed School
More informationUW MEDICINE PATIENT EDUCATION. Angiography: Radiofrequency Ablation to Treat Solid Tumor. What to expect. What is radiofrequency ablation?
UW MEDICINE PATIENT EDUCATION Angiography: Radiofrequency Ablation to Treat Solid Tumor What to expect This handout explains radiofrequency ablation and what to expect when you have this treatment for
More informationGENERAL CONSENT TO TREAT
GENERAL CONSENT TO TREAT DATE: PATIENTS NAME: DATE OF BIRTH: MRN: Consent: I request and authorize medical or surgical treatment as may be deemed necessary and appropriate by the physician and his/her
More informationValparaiso University Student Health Center lmmunotherapy Check List for Allergy patients
Valparaiso University Student Health Center lmmunotherapy Check List for Allergy patients I have read and understood the lmmunotherapy policy and procedure. I have signed the Services Utilization Policy
More informationPlease call the Pharmacy Medicines Unit on or for a copy.
Title: PATIENT GROUP DIRECTION FOR THE SUPPLY OF FLUCONAZOLE 150MG UNDER THE MINOR AILMENT SERVICE Identifier: Across NHS Boards Organisation Wide Directorate Clinical Service Sub Department Area This
More informationMANAGEMENT OF PREVENT AND RESPONSE TO LIFE THREATENING ALLERGIES
File JLDD MANAGEMENT OF PREVENT AND RESPONSE TO LIFE THREATENING ALLERGIES Background The number of students with life-threatening allergies has increased. As with all children with special health care
More informationModule 16. Assisting with Self-Administered Medications
Home Health Aide Training Module 16. Assisting with Self-Administered Medications Goal The goal of this module is to prepare participants to assist clients with self-administered medications. Time 1 hour
More informationFulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 8 Consent for Use and Disclosure of Information 9 Authorization for Use and Disclosure of Protected Health Information 10 Notice
More informationPOLICIES, PENALTIES AND PROCEDURES
POLICIES, PENALTIES AND PROCEDURES Policies exist to eliminate confusion and define for all people involved how things will be done in our practice. That way there is no misunderstanding and no perception
More informationPediatrics How-to Guide for TRICARE Beneficiaries. Readiness Better Care Trusted Care, Anywhere Best Value Better Health
Pediatrics How-to Guide for TRICARE Beneficiaries Pediatric Clinic Operations How to Set Up an Appointment Appointment Line 722-1802 (0700-1630) Call early for same day appointment! 1. The Appointment
More informationPharmacists Impact on Patient Safety
AMERICAN PHARMACISTS ASSOCIATION Pharmacists Impact on Patient Safety A Joint Project of the American Pharmacists Association Academy of Pharmacy Practice and Management and Academy of Pharmaceutical Research
More informationLSU First & WebTPA: Working Together
LSU First & WebTPA: Working Together 2016 LSU First Health Plan Changes 2016 LSU First Health Plan Changes New ID Card Specialty drug copay $150 90 day timely filing period (medical and pharmacy) Home
More informationInfusion Treatment A Patient s Guide
Infusion Treatment A Patient s Guide www.guthrie.org Welcome Thank you for choosing the Guthrie Cancer Center for your medical care. Our team of dedicated professionals will do everything possible to make
More informationNew Patient Registration Form NJR_NP_F100
New Patient Registration Form NJR_NP_F100 Patient Last Name First Name Middle Name Maiden Name Address (Street or Box) City State Zip Code Home Phone Number Cell Phone Number Work Phone Number E-Mail Patient
More informationMRN: (Office Use Only) Patient Information. Legal Name: (Last) Mr. Mrs. Ms. (First) (Middle)
Patient Information MRN: (407) 260-2606 Fax (407) 260-6339 Date: Patient Information Legal Name: (Last) Mr. Mrs. Ms. (First) (Middle) Mailing Address: (Street) (City) (State) (ZIP) Phone: ( ) ( ) ( ) (Home)
More informationYour Choice. 3-Tier Network Option Plan
Your Choice 3-Tier Network Option Plan What is Your Choice? Click Here to Watch Video Your Top Questions What is Your Choice? Are my doctors in the plan? Are my medications covered by the plan? If I get
More informationSTANDARDIZED PROCEDURE HEPATIC ARTERY INFUSION OF CHEMOTHERAPY (Adults, Peds)
I. Definition Hepatic arterial infusion (HAI) of chemotherapy is accomplished by a small drug delivery system or pump that is implanted in a subcutaneous pocket in the lower abdomen. The pump reservoir
More informationMember Service Information
Member Service Information For your EnvisionRx pharmacy benefit & prescription mail order option Support for your pharmacy benefit Register to manage your benefit online To manage your benefits conveniently
More information1. Guidance notes. Social care (Adults, England) Knowledge set for medication. What are knowledge sets? Why were knowledge sets commissioned?
Social care (Adults, England) Knowledge set for medication 1. Guidance notes What are knowledge sets? Part of the sector skills council Skills for Care and Development Knowledge sets are sets of key learning
More informationGeneral Office and Patient Compliance Policies
General Office and Patient Compliance Policies Thank you for choosing Innate Wellness & Medical Center as your medical provider. We are providing you this updated information to keep you informed of our
More informationNATPARA REMS PROGRAM. Frequently Asked Questions (FAQ)
1 2 3 4 5 What is a Risk Evaluation and Mitigation Strategy (REMS)? A Risk Evaluation and Mitigation Strategy (REMS) is a strategy to manage known or potential serious risks associated with a drug or biologic
More informationPATIENT INFORMATION. Patient s Name: Birthdate: ( ) F ( ) M LAST FIRST MI. ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Occupation:
UPON COMPLETION OF PATIENT REGISTRATION PACKET, PLEASE BRING ALL FORMS TO YOUR APPOINTMENT. YOU MAY ALSO FAX COMPLETED FORMS TO THE OFFICE AT 910-575- 9103. THANK YOU. PATIENT INFORMATION Patient s Name:
More informationFulcrum Orthopaedics Patient Registration Packet
Fulcrum Orthopaedics Patient Registration Packet 2 Patient Information Form 9 Consent for Use and Disclosure of Information 10 Authorization for Use and Disclosure of Protected Health Information 11 Notice
More informationPatient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address
Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In
More informationSpecialty Pharmacy How is Traditional Pharmacy Practice Positioned
Specialty Pharmacy How is Traditional Pharmacy Practice Positioned Nick Calla Vice President, Industry Relations Cardinal Health Specialty Solutions August 19, 2016 Today s Learning Objectives Understand
More informationEmergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:
New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient
More information