Drake Center : RECLAST Infusion Referral

5mg/100mL for infusion

Call with questions to: (513) 418-2799

If FAX is needed, fax to: (513) 418-2582

Referring Physician:

J code: J-3488 for Reclast Infusion
Physician's name:

DEA #:

Phone:

Fax:

Patient Information:

Patient's name:

Address:

City:

State: Zip Code:

Phone: Date of Birth:

Diagnosis

Senile Osteoporosis (postmenopausal women/men)
Low-trauma hip fracture

Pathological fracture: Neck of femur
Pathological fracture: Other specified part of femur
Fracture due to injury: Neck of femur

Glucocorticoid-induced osteoporosis
Disorder of bone and cartilage, unspecified
(for prevention of PMO)
Prevention of glucocorticoid- induced osteoporosis
Paget's disease of bone (osteitus deformans)

ICD-9

733.01

733.01 + 733.14

733.01 + 733.15
733.01 + 820.0-820.9

733.09 + E932.0*

733.90

Primary Diagnosis code + V58.65
731.0

* Some payers may require code E932.0 for glucocorticoids causing adverse events in therapeutic use.

THIS PATIENT HAS A CACULATED CREATININE CLEARANCE OF ≥ 35 AND A NORMAL SERUM CALCIUM LEVEL YesNo

(Please attach supporting lab work with referral. Labs need to be within the last 60 days)

DATE OF LAB RESULTS:

PATIENT CURRENTLY TAKING CALCIUM AND VITAMIN D SUPPLEMENTS:Yes No

INSURANCE INFORMATION

PRIMARY INSURANCE: PHONE:

POLICY #: GROUP#:

POLICY HOLDER:

SECONDARY INSURANCE: PHONE:

POLICY #: GROUP #:

POLICY HOLDER:

Along with referral form you have attached lab results prescription insurance card(front and back)

Attach Lab Results here:

Attach Prescription sheet here:

Attach Insurance Card here:

Attach Secondary Insurance Card here:

If you have any questions regarding the patient's appointment or non-clinical questions, please contact our Outpatient Scheduling Department at 513.418.2799.

RECLAST® Infusion Referral
5mg/100mL for infusion
Call with questions to: (513) 418-2799
If FAX is needed, fax to: (513) 418-2582

	Referring Physician: J code: J-3488 for Reclast Infusion Physician's name: DEA #: Phone: Fax: Patient Information: Patient's name: Address: City: State: Zip Code: Phone: Date of Birth:
	Diagnosis Senile Osteoporosis (postmenopausal women/men) Low-trauma hip fracture Pathological fracture: Neck of femur Pathological fracture: Other specified part of femur Fracture due to injury: Neck of femur Glucocorticoid-induced osteoporosis Disorder of bone and cartilage, unspecified (for prevention of PMO) Prevention of glucocorticoid- induced osteoporosis Paget's disease of bone (osteitus deformans) ICD-9 733.01 733.01 + 733.14 733.01 + 733.15 733.01 + 820.0-820.9 733.09 + E932.0* 733.90 Primary Diagnosis code + V58.65 731.0 * Some payers may require code E932.0 for glucocorticoids causing adverse events in therapeutic use. THIS PATIENT HAS A CACULATED CREATININE CLEARANCE OF ≥ 35 AND A NORMAL SERUM CALCIUM LEVEL YesNo (Please attach supporting lab work with referral. Labs need to be within the last 60 days) DATE OF LAB RESULTS: PATIENT CURRENTLY TAKING CALCIUM AND VITAMIN D SUPPLEMENTS:Yes No
	INSURANCE INFORMATION PRIMARY INSURANCE: PHONE: POLICY #: GROUP#: POLICY HOLDER: SECONDARY INSURANCE: PHONE: POLICY #: GROUP #: POLICY HOLDER: Along with referral form you have attached lab results prescription insurance card(front and back)

	Attach Lab Results here: Attach Prescription sheet here: Attach Insurance Card here: Attach Secondary Insurance Card here:
	If you have any questions regarding the patient's appointment or non-clinical questions, please contact our Outpatient Scheduling Department at 513.418.2799.