WEB: ParagardAccessCenter.

com
PHONE: 1-877-PARAGARD

Specialty Pharmacy Request Form

Complete the form below and fax it back to your chosen specialty pharmacy.

SPECIALTY PHARMACY (Choose one)

Specialty Pharmacy Fax Phone Hours of Operation

Biologics by McKesson 1-855-215-5315 1-888-275-8596 Mon-Fri 9:00 AM - 6:00 PM ET

City Drugs 1-212-988-4501 1-855-988-4500 Mon-Fri 9:00 AM - 7:00 PM ET

Sat 9:00 AM - 3:00 PM ET

PATIENT INFORMATION PRESCRIBER INFORMATION

Prescriber Name:
Patient Name:
State Lic #:
Address: NPI #: Specialty:
Facility Name:
City: Address:
City: State: Zip:
State: Ship To Address (Required):
City: State: Zip:
Zip:
Prescriber’s Phone:
Home Phone: Prescriber’s Fax:

PREFERRED COMMUNICATION
Cell Phone:
Office Contact Name:
Date of Birth: Direct Phone Number:
Direct Email Address:
See Attached Demographic Sheet Direct Fax:

INSURANCE INFORMATION (Please attach copies of front & back of cards) N/A (Patient Self-Pay)

Primary Secondary Rx Card

Insurance: Insurance: (PRM):
City: State: City: State: PBM BIN:
Plan #: Plan #: City: State:
Group #: Group #: Group #:
Phone #: Phone #: Phone #:
Subscriber Name (First/Last): Subscriber Name (First/Last): Subscriber Name (First/Last):

ID #: ID #: ID #:
Employer: Employer: Employer:

PRESCRIPTION INFORMATION DIAGNOSTIC INFORMATION (ICD-10 Code)

 AR T380A – QTY 1/Paragard (intrauterine copper

P  30.430: Encounter for insertion of
Z  ther: Please Specify
O
contraceptive) to be inserted one time by prescriber. intrauterine contraceptive device

If patient is a minor and is signing the authorization on the following page on her own behalf, please affirm that:
This patient has the capacity to consent to treatment with Paragard under the law of the state in which I practice (and the consent of a parent or guardian is not required), or

This patient’s parent or guardian has consented to the patient’s treatment with Paragard, as required by applicable state law.

I understand that my signature will be used as an approval allowing the Specialty Pharmacy to dispense Paragard. If I have a financial responsibility for obtaining Paragard,
I understand that the selected specialty pharmacy will contact me prior to the dispense.

Patient Signature: Date: / /

Prescriber Signature: Date: / /
For ARNP, NP, and PA, collaborative physician agreement is with: Date: / /

IMPORTANT: Prescriber gives the selected specialty pharmacy express permission to use his/her NPI number included herein for the purpose of identifying the referring prescriber to the authorized pharmacy benefits
manager and/or payer. The selected specialty pharmacy accepts no liability regarding any decisions concerning claims, coverage or payment, which are made in the sole discretion of the health plan administrators and
insurers. The selected specialty pharmacy makes no assurance that any prescribed drug will be covered or reimbursed at any specific level under any patient’s insurance plan, or that any specific pharmacy will provide
the prescribed drug.
Paragard® is a registered trademark, and Paragard Specialty PharmacySM is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc. C-US-PAR-000022 August 2020

Your healthcare provider has ordered Paragard through the following specialty pharmacy.
This specialty pharmacy may contact you regarding Paragard, or you may contact them
directly if you have any questions.
Specialty Pharmacy Phone Number
Biologics by McKesson 1-888-275-8596
City Drugs 1-855-988-4500
 WEB: ParagardAccessCenter.com
PHONE: 1-877-PARAGARD

Patient Authorization for Specialty Pharmacy

In accordance with the Health Insurance Portability and Accountability Act of 1996 and related federal regulations
and rules (“HIPAA”), this Authorization authorizes my healthcare provider, health plan, and my pharmacy to disclose my
health and personal information to CooperSurgical, Inc. and it’s specialty pharmacy agents (and their affiliates, respective
representatives, and agents) in furtherance of the below-stated authorized purposes.

Authorized Purposes
I understand that the selected specialty pharmacy will receive my health and personal information, which may include
my name, address, patient insurance identification number, date of birth and other information necessary to obtain health
insurance benefit verification for the following purposes: (1) the administration of CooperSurgical’s Paragard Program;
(2) to conduct benefit verification determining insurance reimbursement and coverage of Paragard; (3) to contact me to
discuss any relevant co-pay; (4) bill the insurance company; (5) bill the applicable co-pay; (6) ship the unit to my healthcare
provider; (7) to contact me by telephone in furtherance of conducting benefits verifications investigations and/or specialty
pharmacy dispense; and (8) if I choose to self-pay for Paragard, to invoice me and to otherwise contact me to collect
payment for the Paragard unit.

By signing the following form, I understand:

1. 
Once my healthcare provider gives the selected specialty pharmacy information about me based on this
Authorization, my medical and health information may be subject to redisclosure and is no longer protected by
federal privacy regulations.
I further understand and agree that the selected specialty pharmacy may retain my medical and health information
as disclosed under this Authorization after this Authorization expires.
I also understand that in the event of an audit, and for purposes of such an audit, some information may also
be disclosed to CooperSurgical, Inc., the manufacturer of Paragard, or its affiliates after this Authorization
has expired, so long as the audit is for a period of time when this Authorization was in effect.
2. I may refuse to sign this Authorization form and that, unless allowed by law, my refusal to sign will not affect my
ability to obtain treatment from my healthcare provider; or to seek payment; or my eligibility for insurance benefits.
3. I may revoke my authorization at any time by providing a written notice of same to my healthcare provider, health plan
and/or pharmacy that refers to (or with a copy of) this Authorization form, or to the selected specialty pharmacy.
I understand that if I revoke this Authorization, it will not affect prior disclosures made to the selected specialty pharmacy
and any use of such information by the selected specialty pharmacy in reliance of this Authorization. I understand that
I have the right to receive a copy of this Authorization.
4. This Authorization shall expire one year after I have signed it, or upon revocation, whichever is earlier.

Signature of Patient or Legal Personal Representative: Date: / /

Name of Patient or Legal Personal Representative:

(If Applicable) Description of Personal Representative’s Authority to Sign for Patient:

Please see Important Safety Information and

Full Prescribing Information for Paragard at Paragard.com.
Paragard® is a registered trademark, and Paragard Specialty PharmacySM is a service mark of CooperSurgical, Inc.
© 2020 CooperSurgical, Inc. C-US-PAR-000022 August 2020

Your healthcare provider has ordered Paragard through the following specialty pharmacy.
This specialty pharmacy may contact you regarding Paragard, or you may contact them
directly if you have any questions.
Specialty Pharmacy Phone Number
Biologics by McKesson 1-888-275-8596
City Drugs 1-855-988-4500