Transcription of SERVICE REQUEST FORM KRYSTEXXAConnect
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SERVICE REQUEST FORM KRYSTEXXAConnect
Patient:6. DIAGNOSIS AND THERAPY INFORMATION5. PRIOR AUTHORIZATION ASSISTANCE Please provide chart notes or other clinical information for PA INFUSION FACILITY INFORMATIONP rimary Diagnosis: Chronic Gout without tophi Chronic Gout with tophi Other Patient cannot take xanthine oxidase inhibitors due to contraindication or hypersensitivity reaction Patient s current oral treatment with xanthine oxidase inhibitors has failed to normalize serum uric acid and signs and symptoms are inadequately controlled despite receiving maximum medically appropriate dose of oral urate-lowering therapy (ULT)Gout medications previously tried and failed, with reason for discontinuation: (Provide the information below or include chart notes containing the required information.)Medication, dose Reason Start Date End Date1 2 3 3. PRESCRIBER INFORMATIONName (First, MI, Last): Address: City: State: ZIP: Phone: Gender: Male Female Primary Language: Date of Birth: SSN: Caregiver Name: Phone: Email: Prescriber Name: Practice Name: Address: City: State: ZIP: Phone: Fax: Facility Name: NPI #: Tax ID #: Anticipated Date of First Infusion: SIGNATURE: Date: Medication Acquisition Route: Buy and Bill Specialty Pharmacy: Does the office accept Mastercard ?
INDICATION AND IMPORTANT SAFETY INFORMATION. INDICATIONS AND USAGE. KRYSTEXXA ® (pegloticase) is indicated for the treatment of chronic gout in adult patients who have failed to normalize serum uric acid and
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