Transplant Order Form
2506 Lakeland Drive, Suite 201, Jackson, Mississippi 39232
Pharmacy phone: (866) 420-4041 Pharmacy fax: (601) 420-4040
Patient Information Prescriber Information
Patient name ___________________________________________________________
Prescriber name________________________________________Lic#_________________
ess_______________________________________________________________
DEA#____________________________________Tax ID____________________________
City_________________________________________State_________Zip__________
Transplant Center___________________________________________________________
Home phone___________________________ Cell_____________________________
Contact____________________________________Pager___________________________
DOB_______________________ SSN_______________________________________
Address________________________________________________Rm/FL______________
Drug allergies___________________________________________Male Female
City___________________________________________State_________Zip____________
ge date_____________________________________Time_________________
Office Phone_____________________________ Fax_______________________________
Emergency Contact Name/Phone __________________________________________
Insurance, Medicare or Medicaid Information
Primary Insurance________________________________________________________
Secondary Insurance( If applicable,)_____________________________________________
Policy #________________________________Group____________________________
Policy #___________________________________Group____________________________
Prescripti on Drug Coverage: Company___________________________________________________________ Phone____________________________________________________ RXGRP#___________________________________________RXBIN# ________________________________PCN/ID# (if avail.)_____________________________________________
COMPLETE OR FAX FRONT AND BACK COPIES OF INSURANCE , PRESCRIPTION AND/OR CO-PAY ASSISTANCE CARD(S)
Clinical Information Medical Necessity Additional Information
Transplant date: _______/_______/_______
Was there a prior transplant failure of the same organ? Yes No
Did patient have Medicare A coverage at time of transplant? Yes No
Will patient be enrolled in Medicare B at time of discharge? Yes No
Other:____________________________________ICD-9:_______
Comments__________________________________________________________
Drug Name Strength Directions for Use Refills DAW*
Cellcept ® (Mycophenolate Mofetil) *
* In compliance with applicable state regulations and most insurer policies, Transcript Pharmacy will dispense available FDA-approved generic equivalents, unless DAW is indicated. Deliver to: Patient’s home Discharge Rx’s to Hospital, then remaining refills to patient’s home *PRODUCT SUBSTITUTION PERMITTED UNLESS OTHERWISE INDICATED All discharge orders include: BP Cuf , digital thermometer, medical alert ID bracelet 7 Day QID pill box By signing this form and utilizing our services, you are authorizing Transcript Pharmacy, Inc., its agents and employees, to serve as your prior authorization designated agent in dealing with medical or prescription claims payors, processors and other entities. _____________________________________ _______________________________________________ _________________________________ ________________ Prescriber name or signature Office Contact Name (Nurse, MA, Other) Preferred phone number & extension Date
Miguel Godinho Ferreira Each round of DNA replication results in the erosion of telomeres, the ends of linear chromosomes. Telomerase counteracts telomere shortening by synthesizing new DNA sequences in a time period restricted to late S and G2 cell-cycle phases, even though the enzyme is active throughout the cell cycle. A recent study directly implicates cyclin dependent kinase 1 (Cdk1) in
PRACTICALITIES If you need any help / clarifications / have concerns etc. - Just Say! 1/ Glyn will baptise the men, Emma will baptise the women. Please choose one other person to be in the water to help dunk you! 2/ Bring a change of clothes and a towel – you will be very wet! (have someone holding your towel for when you come out of the water – avoid clothes which turn see-t
Transplant Order Form