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Workers Compensation

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Text of Workers Compensation

  • !!!!!! !Treating)Patients)Special)

    ))

    American Specialty Pharmacy has 4 Pharmacists on site to help ensure quality of compounded products.

    American Specialty Pharmacy has Two State of the Art ISO-5 Class-100

    clean rooms. One for compounding all sterile preparations & one negative pressure chemo room for compounding Chemotherapy medications.

    American Specialty Pharmacy is

    fully compliant with USP797

    E-Prescribing capability with real time order entry and tracking system

    Specialized Customer Service

    One stop for all your

    Pharmaceutical needs

    For all questions or concerns please feel free to call us any time at (877) 868-4110

    Pharmacy Locations

    Plano 2743 W. 15th Street

    Plano, TX 75075 Ph: (214) 919-2090 Fax: (214) 919-2091

    Denton 2436 S. Interstate 35E Suite 360

    Denton, TX 76205 Ph: (940) 383-1222 Fax: (940) 383-1444

    San Antonio 2414 Babcock Rd. Suite 111

    San Antonio, TX 78229 Ph: (210) 615-7400 Fax: (210) 615-7401

    Tyler 1109 E. 5th Street Tyler, TX 75701

    Ph: (903) 533-9100 Fax: (903) 533-9101

    El Paso 1015 N. Zaragoza St.

    El Paso, TX 79907 Ph: (915) 860-7225 Fax: (915) 860-7320

    Miami 2389 SW 22nd Street (Coral Way)

    Miami, FL 33145 Ph: (305) 856-0070 Fax: (305) 856-0072

  • 2743 W. 15th St., Plano, TX 75075Ph: 877-868-4110 Fax: 877-868-4144

    INJECTABLE LISTBetamethasoneAcetate/Phospate (Soluspan)6mg/ml P/F

    2ml vial5ml vial10ml vial

    Size

    Betamethasone Sodium Phospate12mg/ml P/F

    2ml vial (min 20 vials)5ml vial (min 6 vials)

    Size

    Chondroitin / Glucosamine / DMSO

    2ml vial (min 3 vials)Size

    Hyaluronidase150u/ml P/F

    10ml vial preservative freeSize

    Dexamethasone (Decadron equiv.)P/F same price as Triamcinolone(same min. quantities applyTriamcinolone Acetonide P/F 40mg/ml P/F

    1ml vial (min 20 vials)2ml vial (min 20 vials)

    Size

    Methylprednisolone Suspension40mg/ml and 80mg/ml P/F

    2ml vial (min 20 vials)5ml vial (min 6 vials)10ml vial (min 6 vials)

    Size

    Ondansetron2mg/ml

    2ml vial (min 50 vials)Size

    Midazolam* 1-5mg/ml

    1-2ml vial (min 50 vials)Size

    Fentanyl*50mcg/ml

    2ml vial (min 50 vials)Size

    Sodium Bicarbonate 4.2% - 8.4%Size 50ml vial (min 12 vials)Lidocaine 1-2%Size 50ml vial (min 12 vials)

    PLANO - DENTON - TYLER - SAN ANTONIO - EL PASO - MIAMI

  • www.AMERICANSPECIALTYRX.com

    HOW IT WORKS...

    Providing quality & personalizedprescription services for the

    INJURED PERSON

    WE HELP SET UP YOUR PRESCRIPTIONA member of our customer service team will help youset up your prescription and answer any questions that

    you may have.

    WE CALL YOUR INSURANCE & ATTORNEY

    Our dedicated staff will call your carrier to verify thatyour claim is active as well as handle any claim reviewsyour claim is active as well as handle any claim reviews

    and reimbursements.

    WE DELIVER RIGHT TO YOUR DOOR

    We will call and schedule your first delivery.All deliveries are delivered to your door within 24 hours.This service is offered at no out-of-pocket cost to you.

    WE TAKE CARE OF YOUR REFILLS

    YYour refills are filled automatically based on yourprescription or physicians approval.

    It is not necessary to reorder!We bill the insurance carrier directly for all cost.

    We will glady work with your legal counsel to resolveany issues related to your claim.

    DALLAS AREA LOCATIONS

    PLANO 877-868-4PLANO 877-868-4110

    2743 West 15th Street - Suite B - Plano, TX

    EMAIL - [email protected]

    HOURS OF OPERATION

    Mon - Fri 9am until 7pm Sat & Sun 9am until 3pm

  • Providing quality & personalizedprescription services for the

    INJURED PERSONWE TAKE THE BURDEN OFF OF YOU

    Our customer service is second to none; provided by highly

    trained staff. We assist the injured person throughout the

    entire process. From contacting your insurance carrier and

    attorney to automatic refills and overnight delivery.

    Please see reverse side for more detail.

    OUR SERVICESWe are a full service pharmacy that specializes in:

    Letter of Protection

    Workers Compensation Prescriptions

    Compounded & Specialty Medications

    Durable Medical Equipment (DME)

    Nutritional SupplementationNutritional Supplementation

    ABOUT USAt American Specialty Pharmacy, we use the latest

    technology with top quality ingredients to compound safe

    and effective customized medications. Our pharmacists are

    experts at compounding new, discountinued, back-ordered,

    or unavailable medications to meet specific patient needs.

    WWe offer a full line of professional quality vitamins,

    nutritional supplements, OTC medications, medical

    equipment and home delivery. We look forward to serving

    you and meeting your pharmacy needs.

    www.AMERICANSPECIALTYRX.com

  • PATIENT INFORMATION (Use this area or nt demographis)

    Name: ______________________________________ Phone: __________________________ Phone 2: _________________________Home Address: ________________________________________ City: ____________________ State: _______ Zip: _______________ DOB: ______________ SSN: _________________ Sex: Male Female Height: ____________ Weight: _____________Lbs. Allergies: ________________________________________________________________________________________________________

    INSURANCE INFORMATION (Use this area or opy of insuran ard(s)

    Primary Name: _____________________________________ Secondary / RX: _____________________________________________Phone: ___________________________________________ Phone: ____________________________________________________ ID#: _______________________ Group: _______________ ID#: _________________________ Group: ______________________

    MEDICAL ASSESSMENT (Use this area or h paent labs and other authoriz

    Primary Diagnosis: ___________________________________ Secondary / Other Diagnosis: ____________________________________ICD9 Code: _________________________________ ICD9 Code: ______________________________________ Previous Treatment(s): _________________________________________ Outcome: __________________________________________

    PRESCRIPTION INFORMATION *(Use this area or opy of RX(s)

    Prescriber Name: _____________________________________________ NPI#: ____________________________________ Address: _________________________________ City: __________________________ State: _________ Zip: _________ Phone: ______________________________ Fax: ______________________________ Email: _______________________________________ Oce Contact: __________________________________________

    HIVFRMVS.12

    Viscosupplementation InjectableMedication Precertification Request

    PRESCRIBER INFORMATION

    Treating Patients SpecialShip to: Paent Home MD Ke

    /d DKAmerican Specialty to Arrange

    FAX TO: (888) 294-9434

    CALL:(877)753-6877 FAX:(888)294-9434 EMAIL: [email protected]

    Requesting prior authorization for viscosupplementation therapy for: Right knee Left knee both knees Please indicate which drug you are requesting : (P is preferred, NP is non-preferred)

    Eu!exxa (P) Hyalgan (NP) Orthovisc (P) Supartz (NP) Synvisc (NP) Synvisc One (NP) Yes No Does the patient have documented symptomatic osteoarthritis of the knee? Yes No Has the patient had a documented failure after at least 3 months of conservative therapy (including physical therapy, pharmacotherapy, i.e.

    non steroidal anti-in!ammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream)? Yes No Is the patient unable to tolerate conservative therapy because of adverse side e"ects? Yes No Has the patient failed to adequately respond to aspiration and injection of intra-articular steroids? Yes No Does the patient report pain which interferes with functional activities (i.e., ambulation, prolonged standing)?

    If Yes, is the pain attributed to other forms of joint disease? Yes No Yes No Does the patient have any contraindications to the injections (i.e., active joint infection, bleeding disorder)? Yes No Has the patient had a documented trial and failure of Eu!exxa and Orthovisc?

    If Yes, please provide the dates of treatment for both products: Eu!exxa: Orthovisc: If requesting additional series of injections for patient: Date of last injection from prior series:

    Yes No Did the patient respond adequately to the prior series of injections? Yes No Does the patients medical record demonstrate a reduction in the dose of NSAIDs (or other analgesics or anti-in!ammatory medication)

    during the period following the previous series of injections? Yes No Does the patients medical record document signi#cant improvement in pain and functional capacity as the result of the previous injections?

    >/E/>/E&KZDd/KE

    MEDICATION - Refer to CPB # 0179 ASRx DISPENSING? DIRECTIONS QUANTITY

    Eu!exxa (sodium hyaluronate 1%) Yes No

    Hyalgan (sodium hyaluronate) Yes No

    Orthovisc (high molecular weight form of hyaluronic acid) Yes No

    Supartz (sodium hyaluronate) Yes No

    Synvisc (hylan G-F 20) Yes No

    Synvisc One (hylan G-F 20) Yes No

    Please indicate: Start of treatment Continuation of therapy: Right knee Left knee both knees :tnemtaert tsal fo etaD

    T odays date: Date needed:

  • Todays DateNEUROLOGY & PAIN REFERRAL FORMNEW PATIENT CURRENT PATIENT

    2743 West 15th Street, Plano, TX 75075P: 877-753-6877 Fax: 888-966-0188

    PLEASE ATTACH COPIES OF PATIENTS INSURANCE CARDSPRESCRIPTION

    Prescribers SignatureEK^dDW^/DWKZdEEKd/d/

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    &DZ/E^W/>dzW,ZDzat 888-966-0188

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    OSTEOARTHRITIS:d Synovacin'^ Genicin'^Ydz EK,Z Kdd

    SLEEP DISORDER: Somnicin D,dd SentraPM '>'',dW,dYdz d^EZ Kd d

    ADDITIONAL INJURED WORKER MEDICATION Medrox Patches D&WYdz d^EZ Kdd ProcomycinEW>&t&Ydz d&dZ KddSTOOL SOFTNER:d Laxacin^ PromolaxinYdz ZKd d

    FIBROMYALGIA (TOPICAL):*A

    '&WDW C - &'>FORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY: C- &'>'&K''SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL): C- &>

  • New Work Comp / PIP / LOP Information

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    2743 W 15th Street, Plano, TX 75075P: 214-919-2090 Fax: 214-919-2091

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    Notes / Delivery Notes: ________________________________________________________________________

    ___________________________________________________________________________________________

    ___________________________________________________________________________________________

  • www.AMERICANSPECIALTYRX.com

    Plano | Denton | El Paso | San Antonio | Miami | Tyler | Houston