P at i e n t R e f e R R a l f o R m
ALL FIELDS ARE REQUIRED. compLEtE AnD FAx thIS FoRm to (855) 998-6951. FoR ASSIStAncE oR ADDItIonAL InFoRmAtIon, cALL (855) 239-9869
1. PATIENT INFORMATION
2. INSURANCE INFORMATION
o Patient does not have insurance o Insurance information provided below
Name _______________________________ DOB _ _ / _ _ / _ _ _ _ Gender ______
o Copy of both sides of the patient’s insurance card attached
Address ______________________________ City _________________________
Primary insurance ____________________ Insurance phone ______________
State ___________ Zip code _______________ E-mail _____________________
Policy ID # ________________________ Group # _________________________
Home phone ________________________ Cell phone _______________________
Policy holder name _________________ Relationship to patient _______________
Work phone _________________________ Best time to contact ______________ Pharmacy plan _______________ Preferred specialty pharmacy _______________
Patient representative _____________________ Phone ______________________
Policy ID # _______________ Group # ______ RX BIN # ______ RX PCN # ______
3. MEdICAL PROFILE (INFORMATION NEEdEd FOR PRIOR AUThORIzATION SUPPORT)
Drug allergies ______________________________________________________
Other concurrent medications ___________________________________________
Previously tried and failed therapies ______________________________________
Culture results _____________________________________________________
medication needed by date _ _ / _ _ / _ _ _ _
Expected date of discharge _ _ / _ _ / _ _ _ _
4. PRESCRIPTION INFORMATION
o ZYVox 600 mg tablets
o ZYVox 600 mg oral suspension
For NY Prescribers, please provide prescription on NY state prescription form.
5. PATIENT CASE MANAgER CONTACT INFORMATION
6. PRESCRIbER INFORMATION
ZYVOXassist will utilize the preferred communication method below for outreach
Prescriber name _____________________________ Specialty ________________
regarding patient access to oral ZYVox® (linezolid).
Hospital name _____________________________________________________
Contact name ______________________________________________________
Collaborating physician _______________________________________________
preferred communication method (please check At LEASt one method)
o Phone _______________________________________________
City ___________________________ State ________ Zip code _____________
o fax _________________________________________________
State license # ________________________ NPI # ________________________
o Pager _______________________________________________o E-mail address _________________________________________
This form cannot be processed without physician’s signature below.
7. PRESCRIbER SIgNATURE
[ CHECk tO REquESt BENEfItS INvEStIGAtION ONly. If CHECkED, PlEASE SIGN BElOW AND lEAvE RX INfORmAtION BlANk]
By signing this form, I certify that therapy with oral ZYVox is medically necessary for this patient. I will be supervising the patient’s treatment accordingly and I have
reviewed the current oral ZYVox prescribing information. I have received the necessary authorization to release medical and/or other patient information relating to
oral ZYVox therapy to pfizer and its affiliates, service providers, and agents (including US Bioservices) to use and disclose my patient’s health information as necessary
to participate in the ZYVOXassist program, to verify the accuracy of any information provided, to provide reimbursement services, to forward the prescription below to a
pharmacy for fulfillment, and (as applicable) to assess my patient’s eligibility for patient assistance.
DoctoR/pREScRIBER SIgnAtURE—DISpEnSE AS WRIttEn
Please see Important Safety Information and indications on reverse side.
P at i e n t R e f e R R a l f o R m
IMPORTANT SAFETY INFORMATION
ZyvOX® (linezolid) use is contraindicated in patients with known hypersensitivity to ZyvOX or any of
A mortality imbalance was seen in an investigational study in ZyvOX-treated patients with
catheter-related bloodstream infections. ZyvOX is not approved and should not be used for the
ZyvOX should not be used in patients taking any medicinal product which inhibits monoamine
treatment of patients with catheter-related bloodstream infections or catheter-site infections.
oxidases A or B (e.g. phenelzine, isocarboxazid) or within 2 weeks of taking any such product.
ZyvOX has no clinical activity against Gram-negative pathogens and is not indicated for the
treatment of Gram-negative infections. It is critical that specific Gram-negative therapy be
myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) has been
initiated immediately if a concomitant Gram-negative pathogen is documented or suspected.
reported in patients receiving ZyvOX. In cases where the outcome is known, when ZyvOX was
associated diarrhea has been reported with use of nearly all antibacterial
discontinued, the affected hematologic parameters have risen toward pretreatment levels. Complete
agents, including ZyvOX, and may range in severity from mild diarrhea to fatal colitis.
blood counts should be monitored weekly in patients who receive ZyvOX, particularly in those who
receive ZyvOX for longer than two weeks, those with pre-existing myelosuppression, those receiving
unless patients are monitored for potential increases in blood pressure, ZyvOX should not be
concomitant drugs that produce bone marrow suppression, or those with a chronic infection who have
administered to patients with uncontrolled hypertension, pheochromocytoma, thyrotoxicosis and/or
received previous or concomitant antibiotic therapy. Discontinuation of therapy with ZyvOX should be
patients taking any of the following: directly and indirectly acting sympathomimetic, vasopressive,
considered in patients who develop or have worsening myelosuppression.
Peripheral and optic neuropathy have been reported primarily in patients treated with ZyvOX for
lactic acidosis has been reported with the use of ZyvOX. Patients receiving ZyvOX who develop
longer than the maximum recommended duration of 28 days. If patients experience symptoms of
recurrent nausea, vomiting, unexplained acidosis, or a low bicarbonate level should receive immediate
visual impairment, prompt ophthalmic evaluation is recommended. If peripheral or optic neuropathy
occurs, the continued use of ZyvOX in these patients should be weighed against potential risks.
Convulsions have been reported in patients treated with ZyvOX. In some of these cases, a history of
Spontaneous reports of serotonin syndrome including fatal cases have been reported with the
seizures or risk factors for seizures was reported.
co-administration of ZyvOX and serotonergic agents. unless patients are carefully observed for
Postmarketing cases of symptomatic hypoglycemia have been reported in patients with diabetes
signs and/or symptoms of serotonin syndrome or neuroleptic malignant syndrome-like (NmS-like)
mellitus receiving insulin or oral hypoglycemic agents when treated with ZyvOX, a reversible, non-
reactions, ZyvOX should not be administered to patients with carcinoid syndrome and/or patients
selective mAO inhibitor. While a causal relationship between ZyvOX and hypoglycemia has not been
taking any of the following medications: serotonin reuptake inhibitors, tricyclic antidepressants,
established, diabetic patients should be cautioned of potential hypoglycemic reactions when treated
serotonin 5-Ht1 receptor agonists (triptans), meperidine, bupropion or buspirone.
with ZyvOX. If hypoglycemia occurs, a decrease in the dose of insulin or oral hypoglycemic agent, or
discontinuation of oral hypoglycemic agent, insulin, or ZyvOX may be required.
In some cases, a patient already receiving a serotonergic antidepressant or buspirone may require
urgent treatment with ZyvOX. If alternatives to ZyvOX are not available and the potential benefits of
Prescribing ZyvOX in the absence of a proven or strongly suspected bacterial infection or a
ZyvOX outweigh the risks of serotonin syndrome or NmS-like reactions, the serotonergic antidepressant
prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the
should be stopped promptly and ZyvOX administered. the patient should be monitored for two weeks
development of drug-resistant bacteria.
(five weeks if fluoxetine was taken) or until 24 hours after the last dose of ZyvOX, whichever comes
the most commonly reported adverse events (>2%) in adults across phase 3 clinical trials were
first. the patient should also be monitored for discontinuation symptoms of the antidepressant.
ZyvOX formulations are indicated in the treatment of the following infections caused by susceptible
uncomplicated skin and skin structure infections caused by Staphylococcus aureus
strains of the designated microorganisms. ZyvOX is not indicated for the treatment of Gram-negative
susceptible only) or Streptococcus pyogenes
infections. It is critical that specific Gram-negative therapy be initiated immediately if a concomitant
Community-acquired pneumonia caused by Streptococcus pneumoniae
, including cases with
Gram-negative pathogen is documented or suspected.
concurrent bacteremia, or Staphylococcus aureus
(methicillin-susceptible strains only).
Nosocomial pneumonia caused by Staphylococcus aureus
(methicillin-susceptible and -resistant
to reduce the development of drug-resistant bacteria and maintain the effectiveness of ZyvOX
strains) or Streptococcus pneumoniae
and other antibacterial drugs, ZyvOX should be used only to treat or prevent infections that are
Complicated skin and skin structure infections, including diabetic foot infections, without concomitant
proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility
osteomyelitis, caused by Staphylococcus aureus
(methicillin-susceptible and -resistant strains),
information are available, they should be considered in selecting or modifying antibacterial therapy.
, or Streptococcus agalactiae
. ZyvOX has not been studied in the treatment of
In the absence of such data, local epidemiology and susceptibility patterns may contribute to the
vancomycin-Resistant Enterococcus faecium
infections, including cases with concurrent bacteremia.
Pfizer’s service provider performing ZYVOXassist
support services provides patient insurance
services tries to provide correct information, it and Pfizer Inc make no representations or
benefits verification as a service under contract for Pfizer Inc. ZYVOXassist
warranties, expressed or implied, as to the accuracy of the information. the support services
assist health care professionals in the determination of whether treatment could be covered by
administrator, Pfizer Inc, or its employees or agents shall in no event be liable for any damages
the applicable third-party payer based on coverage guidelines provided by the payer, and
resulting from or relating to the services. Responsibility for the use of this service is agreed
patient information provided by the health care provider under appropriate authorization
upon and accepted by all providers and other users of this information.
following the provider’s exclusive determination of medical necessity.
Pfizer Inc does not guarantee, and assumes no responsibility for the quality, scope, or
many factors affect third-party reimbursement. Pfizer Inc and Pfizer’s service provider
availability of the ZYVOXassist
support services including but not limited to reimbursement
performing the ZYVOXassist
support services make no representation or guarantee that
support services, patient education, and other support services. ZYVOXassist
insurance reimbursement or any other payment will be available. this service is for
are included within the cost of the product, and have no independent value to providers apart
informational purposes only. While Pfizer’s service provider performing ZYVOXassist
Bhagavad-Gita – Part Two- Chapter 7 His Holiness Bhakti Caru Swami South African Retreat Day 1: 9th January 2009 Transcription : His Grace Ramavijaya Dasa Editing : Her Grace Hemavati Radhika Dasi Okay so then I will briefly discuss about the seventh chapter which is actually our main… These next few days we will extensively discuss the other chapters of Bhagavadgita. Today as I
Poster Sessions Ⅲ JVIR three main areas relating to periprocedural care, namely sign in, timeStent deployment was successful in all cases. No significant dif-out, and sign out, and requires participation from all members of theferences in prostate size between groups were identified at anyinterventional radiology team. Based on analysis of our initial data,studied timepoints. At day 30 a