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Lysosomal Storage Disorder Patient Information Prescriber + Shipping Information Patient Name: ________________________________ DOB: _____________ Sex: Female Male SSN: ______________________________________ Language: ________________ Wt:______ kg lbs Ht:______ cm in Address: ______________________________________________________ Apt/Suite: ________ City:____________________ State:______ Zip:______ Phone:____________________ Alternate Phone:______________________ Caregiver name: _________________________ Relation: _______________ Local Pharmacy: _________________________ Phone: ________________

Prescriber Name:_______________________________________________ NPI: ________________________________________________________ Address: _____________________________________________________ Apt/Suite: _______ City:____________________ State:______ Zip:______ Contact: ______________________________________________________ Phone: ________________________ Alternate: ______________________ Fax: _________________________________________________________ Email address: ________________________________________________ If shipping to presciber: First Fill Always Never

Insurance Information (Please fax a copy of front and back of the insurance cards) 1 Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________ 2 Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________

Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis: ____________________________________ ICD 10 _________________________ Date of Diagnosis: ______________________________ Access: Peripheral Implanted Port Other__________________________________________Has patient been treated with these products previously? Yes No If yes, product information: _____________________________________________ Date of last infusion: ____________ Date of next infusion: ______________ Comorbidities: __________________________________________________________________________________________________________________ Concomitant Medications:_________________________________________________________________________________________________________ Allergies: NKDA Other: _____________________________________________________________________________________________________

Prescription Oral Enzyme Replacement Therapy Cerdelga

(eliglustat) Take 84 mg once daily by mouth Take 84 mg twice daily by mouth

Quantity:

Anaphylaxis Orders and Medications

Pump and Ancillary Supplies Pump and supplies as needed for administration and appropriate disposal of infusion materials.

Skilled Nursing Visits As needed for IV access, administration and appropriate clinical monitoring.Administration procedures to be followed per pharmacy protocol.

Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise:: __________________________________________

Prescribers Signature:__________________________________________________________________________________ Date: _________________ I authorize Diplomat Pharmacy, Inc. and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any

future fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Diplomat Pharmacy, Inc.

Infusion Enzyme Replacement Therapy

Aldurazyme (laronidase) Cerezyme (imiglucerase)

Elaprase (idursulfase) Fabrazyme (agalsidase beta)

Lumizyme (alglucosidase alfa)l

Myozyme (alglucosidase alfa)

VPRIV (velaglucerase alfa)

Orders: 2. Call 911 and prescribing physician3. Administer medications below as per protocol

Diphenhydramine 50 mg/mL

Quantity: 1 x 50 mg vial

Epinephrine 1 mg/mL

Quantity: 2 vials

Administer 12.5 mg/0.25 mL (weight 30 kg) by slow IV push or IM

Administer ____ mg (0.01 mg/kg or 0.01mL/kg) (weight 30 kg) IM

1. Stop infusion

Refills

Therapy Regimen

Dose: ____________________ units/kg mg/kg Total dose: ____________________ units mg Frequency: __________________ with appropriate reconstitution solution and diluent for administration.Quantity to Dispense: _________________ doses Refills: _____________________ Administration Rate: Per manufacture guidelines, as tolerated ____________________________________________

Pre-Medications and Pre-Protocol

Flushing per Protocol Sodium Chloride 0.9% 5-10 mL pre and post medications Heparin 100 units/mL as needed

The quantity and refills for the flushing protocol medications will match the Enzyme Replacement Therapy requirements.

Sodium Chloride 0.9% Use as directed per protocol Quantity: 1 x 500 mL Bag

Refills:

Dose will be rounded up to the nearest vial size per manufacturers' guidelines.

Pre-medication:______________________________________________________________________________________

Directions: __________________________________________________________________________________________

Quantity: ___________________________________________________________________________________________

Refills: _____________________________________________________________________________________________

Stamp signature not allowed, physician signature required.

Patient Name: DOB: Prescriber Name: NPI: Wt: Address: Address_2: AptSuite: City: Zip: Contact: AptSuite_2: City_2: Zip_2: Phone: Alternate: Phone_2: Alternate Phone: Fax: Caregiver name: Relation: Email address: Local Pharmacy: Phone_3: fill_30: Plan ID: Policy Holder: Relation_2: fill_34: Plan ID_2: Policy Holder_2: Relation_3: Date of Diagnosis: If yes product information: Date of last infusion: Date of next infusion: Comorbidities: Date: State-Pt: [ ]Reset Form: GenericSignature: Language: SSN: Male: Wt-kg: Wt-lbs: Ht-cm: Ht-in: First: All-NKDA: All-Other: Butterfly: Port: PT-Y: PT-N: Female: SuppliesAsNeeded: NursingAsNeeded: Ht: State-Pbr: [ ]Always: Never: OtherAllInfo: Concomitant Meds: mg/kg: units: mg: Cerdelga: Aldurazyme: Elaprase: Lumizyme: Myozyme: CerSig1: CerSig2: Cerezyme: Fabrazyme: VPRIV: units/kg: Diph12: 5:

Diph25: Diph50: Kit refills: Epi11mg/kg: DiphWeight: Epi0: 15: 3:

Dose: Total dose: Daily for: Doses: AdminRate: AsTolerated: AsToleratedInfo: NaCl0: 9:

Pharmacy: [--Select One--]TollFreePhone: PhoneTollFreeFax: FaxSPOC Name: Insert Sales Contact Name (if known)ICD10Diagnosis Code: Other Access: Diagnosis: Other Access Info: CerdelgaRefills: Pre-med: Directions: Quantity: Refills: