Providers - request form for long-acting injectable atypical antipsychotics

Physician Request Form for Long-Acting Injectable Atypical Antipsychotics
Risperdal Consta (Risperidone): 12.5 mg/2ml, 25 mg/2ml, 37.5 mg/2ml, 50 mg/2ml
Invega Sustenna (Paliperidone): 39mg, 78mg, 117mg, 156mg, 234mg
Fax to Pharmacy Services at 855-811-9332, or to speak to a
Representative, call 888-602-3741. Form must be completed for processing.

Patient Name: ____________________________________________________________
Patient ID#: ____________________________________ Address: ____________________________________________________________________ Apt # or Suite #: ________________________________ City: _______________________________________________ State: __________________ Zip Code: ____________________________________ Phone #: __________________________________________ Birth Date: _____________________________________ Physician Name: ____________________________________________________________ NPI #: _________________________________________ Address: ___________________________________________________________________ Apt # or Suite #: _________________________________ City: ____________________________________________________ State: ____________ Zip Code: ______________________________________ Contact Person: ___________________________________ Phone #: ___________________ Fax #: _________________________________________ Physician Signature: _________________________________________________________ Date: __________________________________________ Drug Name: ____________________________________Dosage:_________________________, Frequency of administration:__________________________________ Diagnosis: ______________________________________________________
Please indicate where the medication is being administered: Physician Office_____ Other (Please specify)________________________________

For initial therapy request please fill out Part A, for renewal request please fill out Part B.

Part A- Attach Additional Information as Necessary

1. Does the patient have a history of noncompliance with the prior oral anti-psychotic regimen? (circle answer)
If yes, has the patient been on a drug adherence plan and/or have attempts been made to improve the patients’ compliance (i.e. reminders, self-monitoring tools)?
If Yes, please attach adherence treatment plan or document what adherence measures were done in an attempt to improve compliance:

__________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ 2. Has the patient in the past received oral Risperdal or oral Invega without any significant side effects? (circle answer) Yes or
If yes, please indicate which medication at the dose given. If no, please indicate the complications and provide documentation as needed: __________________________________________________________________________________________________________________________
3. Does the patient have renal and/or hepatic impairment? (circle answer)
If yes, for patients requesting Risperdal Consta, please provide documentation indicating the patient has been able to tolerate at least 2 mg of Risperdal therapy _________________________________________________________________________________________________________________________
Part B- Attach Additional Information as Necessary

1. Has the patient been receiving and tolerating treatment (please attach documentation as needed)? (circle answer) Yes or No
If no, please explain:
_______________________________________________________________________________________________________________________ 2. Provide documentation indicating how the patient has clinically benefited from the treatment: ______________________________________________________________________________________________________________________



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