<p> UniCare Health Plan of Kansas, Inc. State Sponsored Business</p><p>Mirena® (levonorgestrel-releasing intrauterine system) Enrollment Form Fax completed form to: CuraScript Fax number: 1-866-545-0062 | Provider Services phone number: 1-888-662-0944 Part I Patient Information Patient’s last name First name Middle initial </p><p>Address </p><p>City State ZIP code </p><p>Day phone number Night phone number Date of birth ( ) - ( ) - / / Parent/Guardian Allergies Sex M F Primary insurance Secondary insurance </p><p>Cardholder name (if not patient) Cardholder name (if not patient) </p><p>Member ID and Group number BIN# Member ID and Group number BIN# </p><p>Insurance phone number (+area code) Insurance phone number (+area code) ( ) - ( ) - Employer Employer </p><p>Part II Physician Information (please supply copy of patient’s insurance card) Prescriber’s name Hospital/Clinic Office contact name</p><p>Address </p><p>City State ZIP code </p><p>Phone number (+area code) Fax number (+area code) ( ) - ( ) - DEA number NPI UPIN </p><p>Part III Medical Criteria (double click on the fields below to fill in this form electronically) Medical Criteria: Diagnosis: ______ICD-9: ______Yes No: Patient has had at least one child & is requiring contraception for up to 5 years. Yes No: Has the patient had a pregnancy test within the past 2 weeks? If yes, what were the results? Positive Negative Yes No: Is the patient currently using pharmaceutical contraception or used pharmaceutical contraception in the past? If yes, drug(s) used and dates of therapy: Drug: Date: / / Duration: Drug: Date: / / Duration: Drug: Date: / / Duration: Dose the patient have a history of any of the following? Ectopic pregnancy Pelvic inflammatory disease Serious infection within 3 months of pregnancy Immunosuppressive disease Uterine cancer Liver disease / cancer Breast cancer Prescription: One intrauterine device placed in the uterine cavity within 7 day s of onset of menstruation or immediately after first- trimester abortion Prescriber’s signature Date / / CuraScript is able to fill your request as written. Please provide the following information to expedite your order: CuraScript to dispense (check box) Ship medication to: Physician Office/Clinic (Only)</p><p>UniCare Health Plan of Kansas, Inc. ® Registered mark of WellPoint, Inc. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. 0109 KSW2396 11/11 State Sponsored Business, UniCare Health Plan of Kansas, Inc. Mirena® (levonorgestrel-releasing intrauterine system) Enrollment Form Page 2 of 2</p><p>Confidentiality notice: This telecopy transmission contains confidential information belonging to the sender that is legally privileged. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of this document is strictly prohibited.</p>