Pediatrics - Specialists

Phone: (877) 868-4110 Fax: (877) 868-4144

Prescribers and Staff

YOUR ONE-STOP SOLUTION

Our goal is to service all of the needs of your office and your patients.

• A member of our team will fax prescription and patient status updates throughout the prescription process• Prior authorizations to initiate treatment• Re-Authorization to prevent therapy interruption• Cost management•• No cost for delivery to patient home or your office• Injection training for self injectable medications at patient home or in your office• Disease and treatment education prior to therapy initiation• Ongoing side effects management• Customize patient monitoring• Refill reminders and coordination•• Retail prescriptions to ensure patients have ONE PHARMACY• Infusion & Compounding services available

AMERICAN SPECIALTY PHARMACY is able to assist you. We are a SpecialtyPharmacy with retail stores with the ability to fill ALL of your patient’s medications.

Attached you will find a Prescription Referral Form for use with specific chronicillnesses. If your patients also need other medications not listed, just send the

prescription along with it and we’ll take care of that too!

For more information please call or email:

Phone: (877) 868-4110 | Fax: (888) 294-9434 | Email: [email protected]

PLANO,TX | DENTON, TX | SAN ANTONIO | EL PASO, TX | TYLER, TX

www.AMERICANSPECIALTYPHARMACY.com

OUR PRODUCTS & SERVICES We are a full service pharmacy that specializes in:

Compounded & Specialty MedicationsDurable Medical Equipment (DME)

Nutritional SupplementationWorkers’ Compensation Prescriptions

Everyday Prescriptions

WE TAKE THE BURDEN OFF OF YOUOur customer service is second to none; provided by highly trained sta . We assist each patient throughout the entire

process. From contacting your insurance carrier to automatic re lls and overnight delivery.

We look forward to serving you and meeting all of your pharmacy needs.


HOURS OF OPERATIONMon - Fri 9am until 7pm Sat & Sun 9am until 3pm

COMPLIMENTARY DELIVERYAll deliveries are delivered straight to

your door within 24 hours at no out-of-pocket cost to you.

AUTOMATIC REFILLSYour re lls are lled automatically based on

your prescription or physician’s approval. It is not necessary to reorder!

PLANO LOCATION2743 West 15th Street

Plano, TX 75075P: 877-868-4110 . F: 877-868-4144

[email protected]

At American Specialty Pharmacy, we use the latest technology with top quality ingredients to compound safe

and e ective customized medications. Our pharmacists are experts at compounding new, discontinued, back-ordered, or

unavailable medications to meet speci c patient needs.

We o er a full line of Professional Quality Vitamins, Nutritional Supplements, OTC Medications, Everyday

Prescriptions, Medical Equipment & Specialty Medications.


!

!!!CALL:(877)868+4110!!!!!!!!FAX:(888)294'9434)))))))))))))EMAIL:[email protected]!

PATIENT)INFORMATION)(Use)this)area)or)attach)patient)demographics))

Name:!______________________________________!!!Phone:!__________________________!!!Phone!2:!_________________________!Home!Address:!________________________________________!!!City:!____________________!!!State:!_______!!!Zip:!_______________!DOB:!______________!!!SSN:!_________________!!!Sex:!!!!!!!!!Male!!!!!!!!!!Female!!!!!!!!!Height:!____________!!!Weight:!_____________Lbs.!Guardians:_______________________________________________________________________________________________________!

INSURANCE)INFORMATION)(Use)this)area)or)attach)copy)of)insurance)card(s)))

Primary!Name:!_____________________________________!!!!!!!!!Secondary!/!RX:!_____________________________________________!Phone:!___________________________________________!!!!!!!!!!Phone:!____________________________________________________!ID#:!_______________________!!!Group:!_______________!!!!!!!!!!ID#:!_________________________!!!Group:!______________________!!!!MEDICAL)ASSESSMENT)(Use)this)area)or)attach)patient)labs)and)other)authorization)information))

Primary!Diagnosis:!_________________________! ICD9!Code:!________________________! Gestational!Age!____wks!____!days!Secondary!Diagnosis:!_______________________! ICD9!Code:!________________________! Birth!Weight!____kg!or!_____lbs! !Other!current!Treatment(s):!______________________________________________________!!!!!Current!weight!____kg!or!____lbs! !First!injection!already!given?!!! YES!!!!!!! NO!!!!!!!Date!of!first!injection:!____________________!OR!Desired!Start!Date:!______________!!

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

Prescriber!Name:!________________________________________!!!!Contact:_____________________________________!Address:___________________________________!!City:!_________________!!State:!_________! ZIP:!____________!!!Office!Phone:!_________________________!!! ! ! Direct!Fax:!_______________________________________!!!!DEA#:!________________________!!!! St.!License:!___________________________! NPI#:!________________________!Office!Contact!Email:!____________________________________________________________________________________!

*Prescriber)Signature:!_____________________________________________________!!! Date:!_____________!

PRESCRIBER)INFORMATION)

ESPEDFX1112!

SYNAGIS)/)PEDIATRIC)Prescription)Form)

Ship)to:!! !Patient!Home! ! !MD!Office!!!!!!!! !MD!Office!FIRST!FILL!ONLY!

! !!Other:!___________________________!!!Injection)Training:!! !MD!Office! !!! !American!Specialty!to!arrange!!!!!

FAX TO: (888)294-9434

!!!!!!!!!!!!!!

!! !Synagis!(palivizumab)!50mg!and/or!100mg!vials!! !!!!!!Directions:!Inject!15mg/kg!IM!one!time!per!month!–!Q28+30!days!!! !!!!!!Quantity:!____50mg!vials!!!!____100mg!vials!! !!!!!!Refill!______

Other:!_____________________!!!!!Dose:!______________________!!!!!Sig:!!_______________________!!!!!Qty:!_______!!!!!!!Refill:!________!!! !Other:!_____________________!!!!!!Dose:!______________________!!!!!!Sig:!!_______________________!!!!!!Qty:!________!!!!Refill:!________!!

NOTES:!!

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDSPRESCRIPTION

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Today’s DateCOMMONLY USED MEDICATIONS FOR AUTISMϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂǆϴϴϴͲϵϲϲͲϬϭϴϴ

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Today’s Date

PLEASE ATTACH COPIES OF PATIENT’S INSURANCE CARDS

COMPOUNDED NON-STERILE REFERRAL FORM

PRESCRIPTION


Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

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EtWd/EdhZZEdWd/Ed

ϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂǆϴϴϴͲϵϲϲͲϬϭϴϴ

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PRESCRIPTION


Prescriber’s Signature;ƐŝŐŶĂƚƵƌĞƌĞƋƵŝƌĞĚEK^dDW^ͿͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ/DWKZdEEKd/dŚŝƐĨĂǆŝƐŝŶƚĞŶĚĞĚƚŽďĞĚĞůŝǀĞƌĞĚŽŶůǇƚŽƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞ/ƚĐŽŶƚĂŝŶƐŵĂƚĞƌŝĂůƚŚĂƚŝƐĐŽŶĮĚĞŶƟĂůƉƌŝǀŝůĞŐĞĚƉƌŽƉƌŝĞƚĂƌǇŽƌĞǆĞŵƉƚĨƌŽŵĚŝƐĐůŽƐƵƌĞƵŶĚĞƌĂƉƉůŝĐĂďůĞ

ůĂǁ/ĨǇŽƵĂƌĞŶŽƚƚŚĞŶĂŵĞĚĂĚĚƌĞƐƐĞĞǇŽƵƐŚŽƵůĚŶŽƚĚŝƐƐĞŵŝŶĂƚĞĚŝƐƚƌŝďƵƚĞŽƌĐŽƉǇƚŚŝƐĨĂǆWůĞĂƐĞŶŽƟĨǇƚŚĞƐĞŶĚĞƌŝŵŵĞĚŝĂƚĞůǇŝĨǇŽƵŚĂǀĞƌĞĐĞŝǀĞĚƚŚŝƐĚŽĐƵŵĞŶƚŝŶĞƌƌŽƌĂŶĚƚŚĞŶĚĞƐƚƌŽǇƚŚŝƐĚŽĐƵŵĞŶƚŝŵŵĞĚŝĂƚĞůǇ DĞĚŝĐĂƌĞĂŶĚDĞĚŝĐĂŝĚŽƌĂŶŽƚŚĞƌƐƚĂƚĞĨƵŶĚĞĚƉƌŽŐƌĂŵǁŝůůŶŽƚĐŽǀĞƌĂďŽǀĞŵĞŶƟŽŶĞĚĐŽŵƉŽƵŶĚƐŽͲƉĂǇŵĞŶƚƐĚƵĞĂƚĚŝƐƉĞŶƐŝŶŐŽĨƚŚĞŵĞĚŝĐĂƟŽŶ

&ĂǆĐŽŵƉůĞƚĞĚĨŽƌŵƚŽDZ/E^W/>dzW,ZDzĂƚϴϴϴͲϵϲϲͲϬϭϴϴ

WĂƟĞŶƚEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKͺͺͺͺͺͺͺͺͺͺͺͺtĞŝŐŚƚͺͺͺͺͺͺͺDĂůĞ&ĞŵĂůĞ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺƉƚηͺͺͺͺͺͺͺͺͺŝƚǇͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĂǇƟŵĞWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺǀĞŶŝŶŐWŚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺĞůůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺŵĂŝůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺůůĞƌŐŝĞƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ


WƌĞƐĐƌŝďĞƌ ƐEĂŵĞͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺKĸĐĞŽŶƚĂĐƚͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚƌĞĞƚĚĚƌĞƐƐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƵŝƚĞηͺͺͺͺͺͺͺͺͺŝƚǇͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ^ƚĂƚĞͺͺͺͺͺͺͺͺͺͺͺŝƉͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺdĞůͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ>ŝĐĞŶƐĞηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺEW/ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺW^ηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺηͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

EtWd/EdhZZEdWd/Ed

ϮϳϰϯtĞƐƚϭϱƚŚ^ƚƌĞĞƚWůĂŶŽdyϳϱϬϳϱWϴϳϳͲϳϱϯͲϲϴϳϳ&ĂǆϴϴϴͲϵϲϲͲϬϭϴϴ

FIBROMYALGIA (TOPICAL):*AƉƉůǇϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůǇůůŽǁĂƚůĞĂƐƚϮϬŵŝŶƚŽĂďƐŽƌď;ϭƉƵŵƉсϭϱŐŵͿ

Ͳ'ƵĂŝĨĞŶĞƐŝŶϭϬйн&ůƵƌďŝƉƌŽĨĞŶϯϱйн<ĞƚĂŵŝŶĞϯйн>ŝĚŽĐĂŝŶĞϮйнWŝƌŽǆŝĐĂŵϭйнǇĐůŽďĞŶǌĂƉƌŝŶĞϭйнDĂŐŶĞƐŝƵŵŚůŽƌŝĚĞϭϬйнWĞƉƉĞƌŵŝŶƚϬϭйͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйнEŝĨĞĚŝƉŝŶĞϮйнWĞŶƚŽǆǇĨǇůůŝŶĞϮйнůƉŚĂ>ŝƉŽŝĐĐŝĚϮйFORMULAS FOR TOPICAL PAIN/ARTHRITIS/SPASM/NEUROPATHY:ΎŽƐŝŶŐсƉƉůǇϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůǇ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϭϬйͲ&ůƵƌďŝƉƌŽĨĞŶϱйн'ĂďĂƉĞŶƟŶϭϬйн<ĞƚĂŵŝŶĞϭϬйн>ŝĚŽĐĂŝŶĞϱйͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂǌĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϭϬйн<ĞƚĂŵŝŶĞϮйͲ&ůƵƌďŝƉƌŽĨĞŶϱйнǇĐůŽďĞŶǌĂƉƌŝŶĞϭйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲŝĐůŽĨĞŶĂĐϱйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭйͲ&ůƵƌďŝƉƌŽĨĞŶϳйнǇĐůŽďĞŶǌĂƉƌŝŶĞϮйнKƌƉŚĞŶĂĚƌŝŶĞϱйн'ĂďĂƉĞŶƟŶϱйн<ĞƚĂŵŝŶĞϱйͲdƌĂŵĂĚŽůϭϬйнWƌŝůŽĐĂŝŶĞϮйн>ŝĚŽĐĂŝŶĞϰйн'ĂďĂƉĞŶƟŶϯйнĂĐůŽĨĞŶϭй

SHINGLES & TRIGEMINAL NEURALGIA (TOPICAL):ΎƉƉůǇϯ;ϰϱŐŵͿƉƵŵƉƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϯƟŵĞƐĚĂŝůǇ;ϭƉƵŵƉсϭϱŐŵͿͲ&ůƵƌďŝƉƌŽĨĞŶϭϬйнĂƌďĂŵĂǌĞƉŝŶĞϱйн>ŝĚŽĐĂŝŶĞϰйн<ĞƚĂŵŝŶĞϮйнϬϮйϮĞŽǆǇͲͲ'ůƵĐŽƐĞнϯйĐǇĐůŽǀŝƌ

WůĞĂƐĞƐƉĞĐŝĨǇďŽĚǇĂƌĞĂͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ

NEUROPATHIC PAIN & ANTI - INFLAMMATORY SPRAY:ΎƉƉůǇϯ;ϭŵůͿƐƉƌĂǇƐƚŽĂīĞĐƚĞĚĂƌĞĂ;ƐͿϰƟŵĞƐĚĂŝůǇͲ&ůƵƌďŝƉƌŽĨĞŶϳϱйнǇĐůŽďĞŶǌĂƉƌŝŶĞϮйнDĞŶƚŚŽůϯйн>ŝĚŽĐĂŝŶĞϮϬйнD^KͲ<ĞƚĂŵŝŶĞϮϬйнDĞƚŚǇů^ĂůŝĐǇůĂƚĞϯϬйнDĞŶƚŚŽůϯйнD^KͲdƌĂŵĂĚŽůϮϬйнǇĐůŽďĞŶǌĂƉƌŝŶĞϮйнWƌŝŽůŽĐĂŝŶĞϮϱйн>ŝĚŽĐĂŝŶĞϭϮϱйнDĞŶƚŚŽůϯйMIGRAINE HEADACHE:ΎWůĞĂƐĞƐƉĞĐŝĨǇĚŽƐĞĂŶĚĨƌĞƋƵĞŶĐǇͲƌŐŽƚĂŵŝŶĞϭŵŐĂīĞŝŶĞϭϬϬŵŐĞůůĂĚŽŶŶĂϭϬŵŐĂƉƐƵůĞͲƌŐŽƚĂŵŝŶĞdĂƌƚƌĂƚĞϮŵŐ^ƵďůŝŶŐƵĂůdĂďůĞƚƐ^ŝŐͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺZĞĮůůƐͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

Cream Size (Pump): 75gm (Seventy-Five Grams)ϭϬϬŐŵ;KŶĞͲ,ƵŶĚƌĞĚ'ƌĂŵƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ^ŵĂůůĞƐƚ^ŝǌĞϱϬŐŵ;&ŝŌǇ'ƌĂŵƐͿ

Spray Size:ϲϬŵů;^ŝǆƚǇŵŝůůŝůŝƚĞƌƐͿϭϮϬŵů;KŶĞŚƵŶĚƌĞĚdǁĞŶƚǇŵŝůůŝůŝƚĞƌƐͿZĞĮůůƐͺͺͺͺͺͺͺϭ;KŶĞͿϮ;dǁŽͿϯ;dŚƌĞĞͿ

Pediatrics - Specialists

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