Bayer Women’s HealthCare Support Specialty Pharmacy ...

Mirena ICD-9: q q q Other (List ICD-9): _____SIG: To be inserted one time by prescriber. Route intrauterineQuantity: 1 Date of last menses: _____List Allergies: _____Requested Date of Delivery: _____Scheduled Insertion Date: _____Product Substitution Permitted (Signature) Date_____Dispense as Written (Signature) DateI have previously received a Mirena Educational Kit q Ye sI would like to receive a Mirena Educational Kit q Ye sFor ARNP, NP, and PA, collaborative physician agreement is with:_____ Rx Mirena Bayer Women s HealthCare Support Specialty Pharmacy Prescription Request FormLast Name: _____ First Name: _____ MI: _____ Primary Language: _____ Address: _____ City: _____ State: _____ ZIP Code: _____ Phone: _____ Alternate Phone: _____ DOB: _____ Gender: _____ Specialty PharmaciesPatient InformationPatient has no insurance and/or does not want insurance billed.

The Specialty Pharmacy Program prescription process To order Skyla ® or Mirena ®, complete the Specialty Pharmacy Prescription Request Form as follows: 1. Select Specialty Pharmacy. 2. Enter the patient and prescriber information in the space provided on the Specialty Pharmacy Prescription Request Form, including the patient’s pharmacy drug

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  Form, Specialty, Pharmacy, Specialty pharmacy

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