REGISTRATION PACKET AND FORMS

Pharmacy Stocking Form (Form A)

The Pharmacy Stocking Form (Form A) is used by the pharmacy to obtain a supply of The Mylan Brand of Clozapine prior to activation of a CLOZAPINE Prescription Access System (CPAS) access group.  (Please note that if this supply is used, the access group and clozapine-treated patient must be registered with CPAS prior to dispensing the next supply of medication.)

Physician, Pharmacy, and Patient Registration Form (Form B)

The Registration Form (Form B) is used to obtain all registration information for the physician, pharmacist, and patient.  A completed form is necessary for all patients.  Signatures are required for all healthcare providers who are new to treating or dispensing clozapine.

White Blood Cell (WBC) Count and Absolute Neutrophil Count (ANC) Reporting Form (Form C)

The WBC Count and ANC Reporting Form (Form C) accompanies prescriptions when necessary and provides the pharmacist and CPAS with information for dispensing clozapine and monitoring the patient.  This form is designed to provide a copy for each party: the physician, the pharmacist, and CPAS.

Patient-Specific WBC Count and ANC Reporting Form (Form D)

The Patient-Specific WBC Count and ANC Reporting Form (Form D) is used for registered patients.  This triplicate form is designed to provide a copy for each party: the physician, the pharmacist, and CPAS.  Also, it provides the access group with a standard form consisting of all nonvariable information.  Since this form is patient specific, it is not available online. Call CPAS at 1-800-843-9915 to request this form.

The Multiple-Patient WBC Count and ANC Reporting Form (Form E) is available to assist the pharmacist in consolidating numerous WBC Count and ANC Reporting Forms.  This form is designed to provide a copy for each party: the physician, the pharmacist, and CPAS.  The form requests the same patient and Prescribing Information as Form C. It is necessary for CPAS to receive this form within 7 days of the blood draw date for patients who are monitored weekly, within 14 days of the blood draw date for patients who are monitored every 2 weeks, and within 28 days of the blood draw date for patients who are monitored every 4 weeks.