Evenity (Romosozumab)

1. Evenity Insurance Verification Form
2. Evenity Co-pay EFT Authorization Form
3. Evenity Patient Authorization Form
4. Evenity Co-pay Enrollment Form

1. Physician Orders: Beverly Hills
2. Physician Orders: Los Angeles
3. Physician Orders: Santa Monica
4. Physician Orders: Sherman Oaks

Evenity (romosozumab) [Amgen]

• Postmenopausal & male osteoporosis and treatment to increase bone mass in cancer patients
  • 60mg office administered SC q 6 months
• Need past and present DEXA report with T-score (Ca++ and 25 hydroxy-Vit D level if available), height and weight.

Instructions

1. Please open authorization forms at left. Fill out the forms on your computer, save and print.
2. Open Physician Orders for the office of your choice (at left). Save to your computer, print and fill out.
3. Need past and present DXA report (with T score).
4. Send list of medications tried and failed.
5. Fax the following to Pacific Infusion Center (310) 297-9222:
   • Completed and signed forms/order
   • Copy of the patient’s insurance card(s)
   • Demographics
   • OV notes
   • Tried and failed medications
   • Labs
   • Drug Enrollment Forms
6. After the patient’s infusion appointment, one of our nurses will fax a copy of the infusion notes to your office.