Durante mucho tiempo no había principios uniformes para la Atribución de nombres a los antibióticos https://antibioticos-wiki.es . Más a menudo se les llama por el nombre genérico o especie del producto, con menos frecuencia-de acuerdo con la estructura química. Algunos antibióticos se nombran de acuerdo con el lugar donde se asignó el producto.
Medcartpharmacy.com
Toll Free Phone: 877.770.4MEDS(4633)
Toll Free Fax: 877.771.4MEDS(4633) www.medcartpharmacy.com
Patient’s Information Name: _________________________________________________________________________________________________
Patient SS#: ____________________________ DOB:________________ Weight:________________ Height:________________ q Male q Female
Allergies: _____________________________________________________________________________________________________________ q Latex
Address: __________________________________ City: ___________________________________________________ State: ________ Zip: ___________
Home Phone: ______________________________ Work Phone: _______________________________ Cell Phone: _________________________ q Text
Specialty Physician Information Name: _____________________________________________________________________________________
State License #: ________________ UPIN: _________________________ DEA #: ___________________________ NPI #: _______________________
Group or Hospital: _________________________ Phone: _________________________________________________ Fax: _________________________
Address: __________________________________ City: ___________________________________________________ State: ________ Zip: ___________
Contact Person: ____________________________ Phone: _______________________________________________________________________________
Primary Care Physician information Name: _________________________________________ Phone: __________________________________ Insurance Information (Fax copy of patient’s insurance card - both sides)St Current Medications: Comorbid Diseases:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
q Other ___________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Patient Assessment – Hep C: HCV RNA (Baseline) ________________ IU/ml Date of Lab:________________
HCV RNA (12 weeks, if applicable) ________________ IU/ml Date of Lab:________________
Statement of Medical Necessity
HCV Genotype: q1a q1b q2 q3 q4 q5 q6 Pre-Treatment ALT: ________________
Diagnosis (ICD-9 code): Patient Evaluation – HIV:
Has patient been previously treated for Hepatitis C? q Yes q No
Has patient had liver biopsy? q Yes q No • Biopsy date/Results: ________________ ________________
CD4/T-cell count: ______________________________________
Does patient suffer from uncontrolled/life-threatening neuropsychiatric, autoimmune, ischemic, or
infectious disorders, or have a history of autoimmune hepatitis or hepatic decompensation? q Yes q No
If taking ribavirin, is the patient (or patient’s partner) pregnant or unwilling to use adequate contraception,
White blood cell ct: ______________________________________
or is there a history of hemoglobinopathies or renal insufficiency (crcl<50ml/min)? q Yes q No
Prescription Information HIV Medications HIV Medications Continued Medication Strength Directions/Signature Qty Refill Medication Strength Directions/Signature Qty Refill Hepatitis C Medications
Please indicate conv. Pack (includes injection supplies) q Prefilled Syringe q Vial
Please indicate kit (includes injection supplies) q Redipen® q Vial
Hepatitis B Medications Other Medications
Ancillary Supplies and Kits Provided As Needed for Administration
Product Substitution Permitted Signature Date Dispense As Written Signature Date
Ship To: q Patient q Physician/Clinic Date: __________________________________________ Date Shipment Needed: ________________________________________ Rx: q New q Refill
Injection Training/Home Health Coordination:Physician Signature required. q Patient’s Home or Clinic Site q Physician’s Office q No Nurse
Specialty Physician’s name: (please print): ___________________________ Phone: _________________________________________________________
NPI #: __________________________________________________________ Specialty Physician’s signature: _______________________________ M.D. q Injection training is not necessary. Date training occurred: ______________________________________________________________________________ q MD office trained patient q Patient already independent q Referred by MD office to alternate trainer I authorize MedCart Specialty Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process. IMPORTANT NOTICE: This message is intended for use of only the named addressee and may contain information that is proprietary and confidential. If it is received by anyone other than the
named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In
no event should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Reset All Fields
First Time Buyers Well done! The decision to buy a home has proven to be one of the best made for millions of happy home owners. It’s a fact that property is a good investment, especially when you compare it to paying rent. It is important, however to enter the property market with a good understanding of how a property purchase works, what your costs will be and a respect that this is prob
Human intestinal bacteria as reservoirsfor antibiotic resistance genesAbigail A. Salyers, Anamika Gupta and Yanping WangDepartment of Microbiology, University of Illinois, Urbana, IL 61801, USAHuman intestinal bacteria have many roles in humanthrough the human colon on a regular basis are pathogenshealth, most of which are beneficial or neutral for thesuch as Streptococcus pneumoniae and