* = Required Information
Patient Information
Male Female
733.00 Osteoporosis, unspecified
733.01 Senile osteoporosis, postmenopausal osteoporosis
Yes No Not known
Prior Postmenopausal Osteoporosis Treatment History (if any)
Generic Alendronate
Fosamax(alendronate sodium)
Actonel (risedronate sodium)
Boniva (ibandronate sodium)
* The sample diagnosis codes are informational and not intended to be directive or guarantee of reimbursement and include potential codes that would include FDA-approved indications for Prolia. Other codes may be more appropriate given internal system guidelines, payor requirements, practice patterns, and the service rendered.
PHARMACY INSURANCE INFORMATION. (Note: For Medicare patients, provide Pharmacy Insurance Information)
Check one of the following:

Physician Office Patient
Key Safety considerations for Prolia include: hypocalcemia, serious infections, dermatologic adverse events,osteonecrosis of the jaw, and long-term suppression of bone remodeling.
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