STEP ONE: Patient Profile

Name: *     Sex:  * DOB: *
First, Middle, Last mm/dd/yyyy
Address: * City: * State: * ZIP Code: *
SSN: *   Phone: *   Today's Date: *
xxx-xx-xxxx xxx-xxx-xxxx mm/dd/yyyy
Sabril Administration Site:

I authorize my healthcare providers and health plans to disclose personal and medical information related to my use or potential use of Sabril (vigabatrin) to Lundbeck and its agents and contractors and I authorize Lundbeck to use and disclose this information to: 1) establish my benefit eligibility; 2) communicate with my healthcare providers and health plans about my benefit and coverage status and my medical care; 3) provide support services, including facilitating the provision of Sabril to me; 4) evaluate the effectiveness of Sabril's education programs; and 5) participate in the Sabril Patient Registry. I agree that using the contact information I provide, Lundbeck may get in touch with me for reasons related to the SHARE program and may leave messages for me that disclose that I take Sabril.

I understand that once my health information has been disclosed to Lundbeck, privacy laws may no longer restrict its use or disclosure; however, Lundbeck agrees to protect my information by using and disclosing it only for the purposes described above or as required by law. I may also cancel this authorization in the future by notifying Lundbeck in writing and submitting it by fax to 1-877-742-1002 or by calling 1-888-45-SHARE (1-888-457-4273). If I cancel, Lundbeck will cease using or disclosing my information for the purposes listed above, except as required by law or as necessary for the orderly termination of my participation in the SHARE program. I am entitled to a copy of this signed authorization, which expires 10 years from the date it is signed by me. I also certify that the information provided about the insurance status is complete and accurate and will update the SHARE Call Center promptly if such status should change.

Power of Attorney: Power of Attorney (First, Middle, Last):
Patient/Parent/Legal Guardian Signature:
 
 Date:  
mm/dd/yyyy

STEP TWO: Patient Insurance Profile

Name of Primary Payer: *   Phone: *  
xxx-xxx-xxxx
Relationship to Cardholder: *  
Cardholder Name: *   Plan Number: *  
Group Number: *   ID Number: *  
Name of Secondary Payer: Phone:
xxx-xxx-xxxx
Relationship to Cardholder:
Cardholder Name: Plan Number:
Group Number: ID Number:
Prescription Benefit Manager: Phone:
xxx-xxx-xxxx
Cardholder Name: Plan Number:
Group Number: ID Number:

STEP THREE: Prescriber Information

Prescriber's Name (First, Middle Initial, Last): * NPI #: *
Prescriber Address: *
City: * State: * ZIP Code: *
Phone: * Fax: *
xxx-xxx-xxxx xxx-xxx-xxxx

I have completed the Prescriber Enrollment and Agreement Form required for prescribing Sabril.*

I certify that I have reviewed the Medication Guide with the patient/parent/legal guardian, and have counseled him/her on the risks of SABRIL, including vision loss. I commit to ordering and reviewing visual testing at the appropriate intervals in accordance with the SABRIL full prescribing information.

I commit to ongoing patient monitoring including referrals to ophthalmologic professionals for vision assessment in accordance with the SABRIL full prescribing information.

I authorize TheraCom, LLC. in its capacity on behalf of Lundbeck to be my designated agent and to act as my business associate (as defined in 45 CFR 160.103) to use and disclose any information in this form to the insurer of the above-named patient and to obtain any information about the patient, including any protected health information (as defined in 45 CFR 160.103), from the insurer, including eligibility and other benefit coverage information, for my payment and/or health care operation purposes. As my business associate, TheraCom is required to comply with, and by its signature hereto, agrees that it will comply with, the applicable requirements of 45 CFR 164.504(e) regarding business associates, and that it will safeguard any protected health information that it obtains on my behalf, and will use and disclose this information only for the purposes specified herein or as otherwise required by law.

Prescriber Signature:
 
 Date:  
No Stamped Signature mm/dd/yyyy
TheraCom Signature:
 
 Date:  
mm/dd/yyyy

STEP FOUR: Patient History

Name: *  DOB: *  Today's Date: * 
(First, Middle, Last) mm/dd/yyyy mm/dd/yyyy
Race:
History of Sabril Use:
Is the patient currently taking Sabril? * 
Has the patient previously taken Sabril? * 
If the patient has taken or is taking Sabril,
how long were they on drug?		 day(s) week(s) month(s) year(s)
Number Number Number Number
Reason for use: * 
If IS, what is the etiology:

Please check all agents previously or currently utilized by the patient:

Previously Taken Currently Taking
ACTH (Acthar®)
Carbamazepine (Tegretol®)
Clonazepam (Klonopin®)
Diazepam (Valium®)
Other benzodiazepine(s), specify:
Felbamate (Felbatol®)
Gabapentin (Neurontin®)
Ketogenic Diet
Lacosamide (Vimpat®)
Lamotrigine (Lamictal®)
Levetiracetam (Keppra®)
Oxcarbazepine (Trileptal®)
Phenytoin (Dilantin®)
Pregabalin (Lyrica®)
Rufinamide (Banzel®)
Tiagabine (Gabitril®)
Topiramate (Topamax®)
Valproic acid (Depakote®)
Zonisamide (Zonegran®)
Other steroids, specify:
OTHER, specify:

Brand names listed are property of their respective owners.

Please check the # of monotherapy trials by the patient: Please check the # of trials with 2 agents by the patient: Please check the # of trials with 3 or more agents by the patient:









I do not know the details of this patient's medication history.

Explain:

STEP FIVE: Prescription Information

For use by the SHARE Call Center
Prescription: Sabril * 
Quantity: *   ()  * Tablets/Packets
written words digits
*Child Weight (kg): Date: Refills: *   ()  *
mm/dd/yyyy written words digits
Sabril package insert suggested dose titration for patients diagnosed with refractory complex partial seizures: 500 mg (five hundred milligrams) bid week 1. Increase by 500 mg (five hundred milligrams) weekly thereafter until 3 (three) grams per day is reached.
OR
 SIG: *
Primary ICD-9 Code: Secondary ICD-9 Code:
Instructions: Ship to:
Patient Name: *  Address: * 
City: *  State: *  ZIP Code: *  Phone: * 
xxx-xxx-xxxx
Consultant ophthalmic professional:
Scheduled date of baseline visual assessment:
mm/dd/yyyy
Prescriber Signature:
 
  Date:  
No Stamped Signature mm/dd/yyyy
For use by the Specialty Pharmacy
Prescription: Sabril * 
Quantity: *   ()  * Tablets/Packets
written words digits
*Child Weight (kg): Date: Refills: *   ()  *
mm/dd/yyyy written words digits
Sabril package insert suggested dose titration for patients diagnosed with refractory complex partial seizures: 500 mg (five hundred milligrams) bid week 1. Increase by 500 mg (five hundred milligrams) weekly thereafter until 3 (three) grams per day is reached.
OR
 SIG: *
Primary ICD-9 Code: Secondary ICD-9 Code:
Instructions: Ship to:
Patient Name: *  Address: * 
City: *  State: *  ZIP Code: *  Phone: * 
xxx-xxx-xxxx
Consultant ophthalmic professional:
Scheduled date of baseline visual assessment:
mm/dd/yyyy
Prescriber Signature:
 
  Date:  
No Stamped Signature mm/dd/yyyy