Prescription Authorization and Patient Referral Form

Instructions

The Prescription Authorization and Patient Referral Form serves as the initial prescription and HIPAA authorization for your patient.

Using the Upload Additional Documents button below, please provide the following:

A copy of all insurance cards
A copy of patient’s clinical chart notes
if applicable, the At-Home Echo order

If preferred, the prescription can be faxed to 1-888-250-6103.

For any questions or concerns, please contact ONWARD at 888-964-3649.

SECTION 2: PRESCRIBER INFORMATION & PRESCRIPTION

Prescriber Information

Prescriber Name:

Tax ID#:

NPI:

Facility Name:

Facility Address:

City:

State:

ZIP Code:

Name Of Contact Person:

Email:

Phone #:

Fax #:

Preferred method of contact:

Email Phone Fax ONWARD Portal

Prescription Information

Drug: FINTEPLA (fenfluramine) 2.2 mg/mL oral solution

Patient’s Weight (kg):

Gastric Feeding Tube: Yes No

Sig.
Take: mL (round to the nearest tenth) PO BID for days,

Take: mL (round to the nearest tenth) PO BID for days,

Take: mL (round to the nearest tenth) PO BID thereafter

Special Instructions

Quantity (based on maintenance dose): mL Days’ Supply: Refills:

New Suggested Titration Schedule*
	Weight-based dosing^†	Calculated Dose Examples for Patients Weighing:
	Weight-based dosing^†	22 kg	44 kg	66 kg
Initial Dose	0.1 mg/kg BID	1 mL BID	2 mL BID	3 mL BID
Titration Dose (Day 7)	0.2 mg/kg BID	2 mL BID	4 mL BID	5.9 mL BID
Maintenance Dose (Day 14)	0.35 mg/kg BID	3.5 mL BID	5.9 mL BID	5.9 mL BID
Maximum total daily dose mg: 26 mg^* (13 mg BID)		Maximum total daily dose mL: 11.8 mL^* (5.9 mL BID)

* If patient is taking stiripentol or a strong CYP1A2 or CYP2D6 inhibitor; has severe renal impairment; or has mild, moderate, or severe hepatic impairment, see full Prescribing information for dose adjustments and maximum dosage.

^† To calculate: Weight (kg) x dosage (mg/kg) ÷ 2.2 mg/mL = mL dose BID.

Diagnosis (Describe how diagnosis was made and attach supporting documentation/test results)

ICD-10 Code:

G40.83 (DS); Polymorphic epilepsy in infancy (PMEI); Severe myoclonic epilepsy in infancy (SMEI)
G40.833 (DS) intractable, with status epilepticus	G40.834 (DS) intractable, without status epilepticus
G40.81 (LGS)	G40.811 (LGS) not intractable, with status epilepticus
G40.812 (LGS) not intractable, without status epilepticus	G40.813 (LGS) intractable, with status epilepticus
G40.814 (LGS) intractable, without status epilepticus	Other ICD-10:

Patient's Echocardiogram

If the patient/caregiver has decided where they would like to obtain the required echocardiogram, please indicate where:

Hospital-based Facility Outpatient Imaging Center At Home* LTC Facility Other Undecided

Patient's echocardiogram (echo) has been scheduled and/or completed:

Yes No

If yes: Patient's echo appointment date:

*Patients participating in UCB's At-Home Echo Program must affirmatively opt-in through ONWARD and agree to the comply with the Program's terms and conditions. For participating patients, an echo order will need to be faxed to ONWARD 1-888-250-6103.

Prescriber Agreement

By signing below, I certify: 1) The therapy is medically necessary and that this information is accurate to the best of my knowledge; 2) I am disclosing this information to UCB, their affiliates, agents, representatives, business partners, and service providers (together “UCB”) to help enable treatment for this Patient; 3) The Patient is aware of, has consented to, and has directed my disclosure of their information to UCB so that UCB may contact the Patient to further enable services for those purposes and that such consent and direction applies to disclosures made through the duration of the Patient's therapy; 4) I will not seek reimbursement from any third party for the support UCB provides; and 5) I am licensed to prescribe the prescription medication identified in this form, the prescription complies with my state-specific prescribing requirements and I appoint UCB as my agent for the limited purposes of conveying this prescription by any means under applicable law only to the dispensing pharmacy. I understand that by signing this form, I am requesting support from UCB for Patients receiving FINTEPLA®. PRESCRIBER SIGNATURE: PRESCRIBER MUST MANUALLY SIGN AND DATE. RUBBER STAMPS AND SIGNATURE BY OTHER OFFICE PERSONNEL FOR THE PRESCRIBER WILL NOT BE ACCEPTED.

To proceed to signature, click Next Step below.

PROVIDER PORTAL

Prescription Authorization and Patient Referral Form

Instructions

SECTION 1: PATIENT / INSURANCE INFORMATION

Patient Information

Insurance Information