OncologyHematologic Cancer (A-J)(Bosulif®, Farydak®, Gleevec®, Imbruvica®, Jakafi®)Patient Information Prescriber + Shipping InformationPatient name: ________________________ DOB: _____________Sex: Female Male SSN: ______________________________Language: ____________ Wt: _____ kg lbs Ht: _____cm inAddress: _______________________________________________Apt/Suite: _____ City: ________________ State: _____ Zip: ______Phone: ___________________ Alternate: ____________________Caregiver name: ____________________ Relation: _____________Local pharmacy: _____________________ Phone: _____________Insurance plan: _________________ Plan ID: ________________Please fax a copy of front and back of the insurance card(s).

Prescriber name: _______________________________________

NPI: _________________________________________________

Address: ______________________________________________Apt/Suite: ______ City: ____________ State: _______ Zip: ______Contact: ______________________________________________ Phone: _____________________ Alternate: _________________Fax: _________________________________________________Email: ________________________________________________If shipping to prescriber: First Fill Always

Clinical Information (Please fax all pertinent clinical and lab information)Diagnosis (C00-D49): _____________________________________________________________ Diagnosis date: _________________Patient Type (if applicable): Adult female NOT of reproductive potential Adult female of reproductive potential Adult male Date: _____________________ Child female NOT of reproductive potential Child female of reproductive potential Child male Authorization: _______________Mutations: 17p deletion _______________Lymph node size: _____ cm Absolute Lymphocyte count: _______/L TLS Risk: Low Moderate High Date: _________________Prior Therapy Yes No Reason for Discontinuation of Therapy Approximate Start Date Approximate End Date____________________________________________________________________________________

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Comorbidities: ___________________________________________________________________________________________________Concomitant Medications: __________________________________________________________________________________________Allergies: NKDA Other: _______________________________________________________________________________________Prescription Quantity Refill

Bosulif®

(bosutinib) Take 500 mg once daily by mouth with food ___________________________________________________________

30 x 500 mg tablets __________________

______

Farydak®

(panobinostat)

Take 20 mg once daily by mouth on days 1, 3, 5, 8, 10 and 12 of a 21-daycycle

___________________________________________________________

6 x 20 mg capsules ___________________

______

Dexamethasone Take 20 mg once daily by mouth with food on days 1, 2, 4, 5, 8, 9, 11, and 12 of a

21-day cycle ___________________________________________________________________

8 x 20 mg capsules ___________________

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Aspirin Take 81 mg once daily by mouth ___________________________________________________________________

28 x 81 mg tablets ___________________

______

Gleevec®

(imatinib)

Take 400 mg once daily by mouth with a meal and full glass of water Take 600 mg once daily by mouth with a meal and full glass of water

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30 x 400 mg tablets 30 x 400 mg tablets

60 x 100 mg tablets ___________________

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Imbruvica®

(ibrutinib)

Take 420 mg once daily by mouth with a full glass of water Take 560 mg once daily by mouth with a full glass of water ___________________________________________________________

90 x 140 mg capsules 120 x 140 mg capsules ___________________

______

Jakafi®

(ruxolitinib) Take _______ mg once daily by mouth Take _______ mg twice daily by mouth

30 x ____ mg tablets 60 x ____ mg tablets

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§ Ninlaro®, Pomalyst®, Revlimid®, Sprycel®, Synribo®, Tasigna®, Thalomid®, Venclexta™, Zolinza®, and Zydelig® are listed alphabetically on respective enrollment forms§

Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: ____________________________

Prescriber’s Signature:__________________________________________________________________________ Date: ______________

For patients requiring immune globulin therapy, please fill out the respective form: IVIg or SCIg.

225 Route 46 West Suite 3Totowa, NJ 07512

Phone: 973-837-6877Fax: 973-837-6878