Get the free White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form

This form is used by physicians to request white blood cell stimulators for patients, including Leukine®, Neupogen®, and Neulasta®. It captures patient information, physician details, treatment

How to fill out white blood cell stimulators

How to fill out White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form

1. Obtain the White Blood Cell Stimulators Physician Request Form.
2. Fill in the patient's personal information at the top of the form, including name, date of birth, and medical record number.
3. Specify the diagnosis that requires the use of the white blood cell stimulators.
4. Indicate the chemotherapy treatment regimen the patient is receiving.
5. Document any previous treatment with white blood cell stimulators, including dates and outcomes.
6. Include the specific white blood cell stimulant requested (Leukine®, Neupogen®, Neulasta®).
7. Provide any relevant laboratory test results that support the need for the medication.
8. Sign and date the form at the bottom.
9. Submit the completed form to the relevant insurance provider or medical office.

Who needs White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form?

1. Patients undergoing chemotherapy who are at risk of neutropenia.
2. Patients with certain types of cancer that require support for white blood cell production.
3. Individuals with a history of severe infections related to low white blood cell counts.
4. Patients who are undergoing bone marrow transplantation.

People Also Ask about

How long can you be on NEUPOGEN?

A transient increase in neutrophil count is typically seen 1 to 2 days after initiation of NEUPOGEN therapy. Therefore, to ensure a sustained therapeutic response‚ administer NEUPOGEN daily for up to 2 weeks or until the ANC has reached 10‚000/mm3 following the expected chemotherapy-induced neutrophil nadir.

What is Neulasta used for?

Neulasta® is a prescription medicine used to help reduce the chance of infection due to a low white blood cell count, in people with certain types of cancer (non-myeloid), who receive anti-cancer medicines (chemotherapy) that can cause fever and low white blood cell count.

Does NEUPOGEN cause weight gain?

Call your doctor or seek emergency medical attention right away if you have fever with shortness of breath or rapid breathing, stuffy or runny nose followed by tiredness, thirst, decreased urination, and sudden swelling or weight gain. Neupogen can cause your spleen to become enlarged and rupture (tear).

How much does Neulasta cost?

For more information on paying for Neulasta® Onpro®, find your insurance type below. Amgen is committed to help ensure you will be able to get Neulasta® Onpro® at an affordable cost. As of Q1 2024 the list price for Neulasta® is $6,418.0* per dose. Neulasta® is a single dose administered once per chemotherapy cycle.

What is NEUPOGEN used to treat?

NEUPOGEN ® is used to treat neutropenia, a condition where the body makes too few neutrophils. Neutrophils are a type of white blood cell important in the body's fight against infection.

What is the difference between Neulasta and NEUPOGEN?

Neupogen () is a short-acting medication that's given daily for several days. Neulasta (pegfilgrastim) is a longer-acting medication that's administered only once after a chemotherapy session. Neupogen and Neulasta are both available as reference medications.

What is NEUPOGEN prescribed for?

Neupogen® is given to help cancer patients and patients exposed to high doses of radiation produce white blood cells. By producing white blood cells at a faster pace, Neupogen® helps to avoid or minimize the incidence of infections from neutropenia.

Does NEUPOGEN always work?

NEUPOGEN helps most people but it may have unwanted side effects in some people. All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

For pdfFiller’s FAQs

What is White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form?

The White Blood Cell Stimulators Physician Request Form is a document used by healthcare providers to request authorization for the use of White Blood Cell Stimulators, specifically Leukine®, Neupogen®, and Neulasta® for their patients.

Who is required to file White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form?

Healthcare providers including physicians, oncologists, and other licensed practitioners who prescribe White Blood Cell Stimulators for patients are required to file this form.

How to fill out White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form?

To fill out the form, the healthcare provider needs to provide patient information, details regarding the diagnosis, treatment history, and the specific reasons for prescribing the White Blood Cell Stimulator along with necessary identification and insurance details.

What is the purpose of White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form?

The purpose of this form is to ensure that the use of White Blood Cell Stimulators is medically necessary and to obtain insurance approval for the prescription, ensuring that patients receive the needed treatment.

What information must be reported on White Blood Cell Stimulators (Leukine®, Neupogen® Neulasta®) Physician Request Form?

The information that must be reported includes patient demographics, medical history, current treatment regimen, specific indications for use, previous responses to treatments, and any other relevant clinical information.