Last name: ____________________________________________________________ First name: ____________________________________________________________
Address: ______________________________________________________________ City: __________________________________ State: _______ ZIP: ______________
Cell phone #: ________________________________Home phone #: __________________________________ Email: ___________________________________________
Gender: o Male o Female Date of birth: _______/_______/________ SSN (for insurance verification purposes only): _____________________________________
1. Patient Information
ICD-10 Code: o M17.0 o M17.11 o M17.12 o M17.2 o M17.31 o M17.32 o M17.4 o M17.5 o Other: __________________________________________
Select the appropriate injection-site location: o Left knee o Right knee o Bilateral
Clinical Information — Has the patient tried any of the following? (Please check all that apply):
o Immediate release intra-articular steroids (date of last injection: _____/_____/________) o NSAIDS o Analgesics o Physical therapy/exercise program
o Other (list all that apply): _____________________________________________________________________________________________________________________
o ZILRETTA (date of last injection: _____/_____/________) (select previous injection-site location): m Left knee m Right knee m Bilateral
Known drug allergies and notes: _________________________________________________________________________________________________________________
4. Diagnosis and Clinical Information
ZILRETTA
®
(triamcinolone acetonide extended-release injectable suspension), 32 mg (5 mL) Quantity: ___________
Directions for use: Administer ZILRETTA as a single intra-articular injection of triamcinolone acetonide, 32 mg (5 mL) for extended-release. ZILRETTA is supplied as a
single-dose kit containing a vial of 32 mg sterile triamcinolone acetonide (extended-release), 5 mL of sterile diluent, and a sterile vial adapter. Prepare using the diluent
supplied in the kit. Refer to the “Instructions for Use” provided with the kit for preparation and administration of ZILRETTA.
Additional directions:
_________________________________________________________________________________________________________________________
Dispense as written
Please attach a separate prescription if this section does not comply with your state’s prescription law. Prescriptions from New York must be issued electronically.
By signing below, I certify that (1) the above therapy is medically necessary and in the best interest of the patient listed above; (2) I authorize Flexion Therapeutics, Inc.
and its contractors and business partners (“Contractors”) to (i) supply any information to the insurer of the above named patient, (ii) forward the above prescription by
fax or other means of delivery to a licensed pharmacy, and (iii) verify benefits and coordinate the dispense of ZILRETTA where appropriate; and (3) I understand that
information I provide on this form, if signed by the patient, will be used by Flexion Therapeutics, Inc. and its Contractors as authorized by the patient.
Healthcare professional name (please print):
______________________________________________________________________________________________________
Healthcare professional signature: _____________________________________________________________________________________ Date: _____/_____/________
5. Prescription Information
6. Physician Authorization
Last name: _____________________________________________________________First name: ___________________________________________________________
NPI #: _____________________________State license #: ____________________________ Tax ID #: _________________________DEA #: _________________________
Office name: _________________________________________________________________________________________________________________________________
Address: ______________________________________________________________City: __________________________________ State: ________ZIP: ______________
Phone #: ______________________________________________________________Fax #: ________________________________________________________________
Primary Contact
Last name: __________________________________________First name: __________________________________Title: _______________________________________
Email: ______________________________________________Phone #: ____________________________________Fax #: ______________________________________
Preferred method of contact: o Phone o Email
2. Prescriber Information
Fax us the completed enrollment form
at 1-866-558-7939
Call us at 1-844-FLEXION (1-844-353-9466),
Monday - Friday, 8 am - 8 pm ET
Attach a copy of both sides of the patient’s insurance card(s) and/or fill out the insurance information below.
Is the patient enrolled in a government-funded healthcare program such as Medicare, Medicaid, VA, DoD, TRICARE, a qualified health plan (QHP), or a plan offered under a
state or federal exchange? o Yes o No
Primary Insurance
Plan name:
__________________________________________________________
ID #:____________________________ Group #: ____________________________
Plan phone #: ________________________________________________________
Policy holder: ________________________________________________________
Date of birth of policy holder (if different from patient): _______/_______/________
Relationship to patient: ________________________________________________
o Patient is uninsured
3. Insurance Information
Secondary Insurance
Plan name: __________________________________________________________
ID #:____________________________ Group #: ____________________________
Plan phone #: ________________________________________________________
Policy holder: ________________________________________________________
Date of birth of policy holder (if different from patient): _______/_______/________
Relationship to patient: ________________________________________________
o Benefits Investigation Only
o Specialty Pharmacy Triage
Services (please check all that apply)
o Full Benefits Support (benefits investigation,
prior authorization, and appeals support)
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FlexForward
®
Enrollment Form
Fax completed enrollment form to 1-866-558-7939
