Specialty Pharmacy Request Form

Paragard

is a registered trademark, and Paragard Specialty Pharmacy

is a service mark of CooperSurgical, Inc.

If patient is a minor and is signing the authorization on the following page on her own behalf, please arm that:

This patient has the capacity to consent to treatment with Paragard under the law of the state in which I practice (and the consent of a parent or guardian is not required), or

This patient’s parent or guardian has consented to the patient’s treatment with Paragard, as required by applicable state law.

WEB: ParagardAccessCenter.com

PHONE: 1-877-PARAGARD

Patient Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Date of Birth:

See Attached Demographic Sheet

Prescriber Name:

State Lic #:

NPI #: Specialty:

Facility Name:

Address:

City: State: Zip:

Ship To Address (Required):

City: State: Zip:

Prescriber’s Phone:

Prescriber’s Fax:

PREFERRED COMMUNICATION

Oce Contact Name:

Direct Phone Number:

Direct Email Address:

Direct Fax:

PATIENT INFORMATION PRESCRIBER INFORMATION

Primary

Insurance:

City: State:

Plan #:

Group #:

Phone #:

Subscriber Name (First/Last):

ID #:

Employer:

Secondary

Insurance:

City: State:

Plan #:

Group #:

Phone #:

Subscriber Name (First/Last):

ID #:

Employer:

Rx Card

(PRM):

PBM BIN:

City: State:

Group #:

Phone #:

Subscriber Name (First/Last):

ID #:

Employer:

INSURANCE INFORMATION (Please attach copies of front & back of cards)

PAR T380A – QTY 1/Paragard (intrauterine

copper contraceptive)

PRESCRIPTION INFORMATION

Z30.430: Encounter for insertion of

intrauterine contraceptive device

Other: Please Specify

DIAGNOSTIC INFORMATION (ICD-10 Code)

Patient Signature: Date:

Prescriber Signature:

Date:

For ARNP, NP, and PA, collaborative physician agreement is with:

Date:

IMPORTANT: Prescriber gives the selected specialty pharmacy express permission to use his/her NPI number included herein for the purpose of identifying the referring prescriber to the authorized pharmacy beneﬁts

manager and/or payer. The selected specialty pharmacy accepts no liability regarding any decisions concerning claims, coverage or payment, which are made in the sole discretion of the health plan administrators and

insurers. The selected specialty pharmacy makes no assurance that any prescribed drug will be covered or reimbursed at any speciﬁc level under any patient’s insurance plan, or that any speciﬁc pharmacy will provide

the prescribed drug.

Specialty Pharmacy PhoneFax

SPECIALTY PHARMACY (Choose one)

Biologics by McKesson

City Drugs

1-855-215-5315

1-212-988-4501

1-888-275-8596

1-855-988-4500

Hours of Operation

Mon-Fri 9:00 AM - 6:00 PM ET

Mon-Fri 9:00 AM - 7:00 PM ET

Sat 9:00 AM - 3:00 PM ET

Complete the form below and fax it back to your chosen specialty pharmacy.

Specialty Pharmacy

Biologics by McKesson

City Drugs

Your healthcare provider has ordered Paragard through the following specialty pharmacy.

This specialty pharmacy may contact you regarding Paragard, or you may contact them

directly if you have any questions.

I understand that my signature will be used as an approval allowing the Specialty Pharmacy to dispense Paragard. If I have a ﬁnancial responsibility for obtaining Paragard,

I understand that the selected specialty pharmacy will contact me prior to the dispense.

Phone Number

1-888-275-8596

1-855-988-4500

Patient Authorization for Specialty Pharmacy

In accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations

and rules (“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my

health and personal information to CooperSurgical, Inc. and it’s specialty pharmacy agents (and their aliates, respective

representatives, and agents) in furtherance of the below-stated authorized purposes.

Authorized Purposes

I understand that the selected specialty pharmacy will receive my health and personal information, which may include

my name, address, patient insurance identiﬁcation number, date of birth and other information necessary to obtain health

insurance beneﬁt veriﬁcation for the following purposes: (1) the administration of CooperSurgical’s Paragard Program;

(2) to conduct beneﬁt veriﬁcation determining insurance reimbursement and coverage of Paragard; (3) to contact me to

discuss any relevant co-pay; (4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare

provider; (7) to contact me by telephone in furtherance of conducting beneﬁts veriﬁcations investigations and/or specialty

pharmacy dispense; and (8) if I choose to self-pay for Paragard, to invoice me and to otherwise contact me to collect

payment for the Paragard unit.

By signing the following form, I understand:

1. Once my healthcare provider gives the selected specialty pharmacy information about me based on this

Authorization, my medical and health information may be subject to redisclosure and is no longer protected by

federal privacy regulations.

I further understand and agree that the selected specialty pharmacy may retain my medical and health information

as disclosed under this Authorization after this Authorization expires.

I also understand that in the event of an audit, and for purposes of such an audit, some information may also

be disclosed to CooperSurgical, Inc., the manufacturer of Paragard, or its aliates after this Authorization

has expired, so long as the audit is for a period of time when this Authorization was in eect.

2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not aect my

ability to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance beneﬁts.

3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider, health plan

and/or pharmacy that refers to (or with a copy of) this Authorization form, or to the selected specialty pharmacy.

I understand that if I revoke this Authorization, it will not aect prior disclosures made to the selected specialty pharmacy

and any use of such information by the selected specialty pharmacy in reliance of this Authorization. I understand that

I have the right to receive a copy of this Authorization.

4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.

Signature of Patient or Legal Personal Representative: Date:

Name of Patient or Legal Personal Representative:

(If Applicable) Description of Personal Representative’s Authority to Sign for Patient:

WEB: ParagardAccessCenter.com

PHONE: 1-877-PARAGARD

Please see Important Safety Information and

Full Prescribing Information for Paragard at Paragard.com.

Paragard

is a registered trademark, and Paragard Specialty Pharmacy

is a service mark of CooperSurgical, Inc.

Specialty Pharmacy

Biologics by McKesson

City Drugs

Your healthcare provider has ordered Paragard through the following specialty pharmacy.

This specialty pharmacy may contact you regarding Paragard, or you may contact them

directly if you have any questions.

Phone Number

1-888-275-8596

1-855-988-4500