PhytogenixRx

Patient Information

Full Name

Date of Birth

Daytime Phone

Patient Address

City

State

Zip Code

Medicare / Insurance Provider

Insurance ID Number

Prescriber Information

Provider Name & Title

NPI Number

Clinic Phone

Custom Multi-Modal Pain Cream

Formulation Base: Versapro Cream Base (Hypoallergenic Vehicle)

Active Ingredients

Concentration / Notes

Ketoprofen

Diclofenac Sodium

Gabapentin

Cyclobenzaprine HCl

Baclofen

Versapro Cream Base

Directions for Use (Sig)

Quantity to Dispense

Letter of Medical Necessity & Diagnostic Justification

Please check all applicable ICD-10 codes and necessity parameters to justify this specific multi-modal formulation.

OFFICIAL STATEMENT OF MEDICAL NECESSITY: I certify that the prescribed customized compounded medication is medically necessary for this patient. I have evaluated the patient's medical history, and standard commercially available FDA-approved formulations are clinically contraindicated, unavailable, or have been previously ineffective for the management of this patient's condition. This treatment plan is in accordance with accepted standards of medical practice. I understand that this information will be used for HIPAA-compliant adjudication and care coordination.

Supply

30 Days 60 Days 90 Days

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Prescriber Signature

Date

CONFIDENTIALITY NOTICE: This document contains Protected Health Information (PHI) intended strictly for the use of PhytogenixRx.

Custom Multi-Modal Pain Cream

Inflammation (NSAIDs)

Neuropathic Pain

Muscle Spasticity