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Immune Globulins (Ig) Enrollment Form Fax Referral To: 1-866-843-3221 Phone: 1-866-899-1661 Email Referral To: [email protected]
Six Simple Steps to Submitting a Referral uPATIENT INFORMATION (Complete or include demographic sheet) v PRESCRIBER INFORMATION Patient Name: ______________________________________ Prescriber’s Name: ______________________________________ Address: ______________________________________ State License #: ______________ NPI #: ______________ City, State, ZIP: ______________________________________ DEA #: ______________ Preferred Contact
Method: Phone
(to primary # provided below) Text
(to cell # provided below) Email
(to email provided below) Group or Hospital: ______________________________________ Note: Carrier charges may apply. If unable to contact via text or email, Specialty Pharmacy will attempt to contact by phone. Address: ______________________________________
Primary Phone: ___________ Home Cell Work City, State, ZIP: ______________________________________ Alternate Phone: ___________ Home Cell Work Phone: ______________________________________ DOB: ___________ Gender: Male Female Fax: ______________________________________ Email: ______________________________________ Contact Person: ______________________________________ Last Four of SSN: ___________ Primary Language: _________ Contact’s Phone: ______________________________________
wINSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back)
xDIAGNOSIS AND CLINICAL INFORMATION Needs by Date: ______________ Ship to: Patient Office Other: __________ Diagnosis (ICD-10):
D80.0 Congenital Hypogammaglobulinemia D81.9 SCID (Unspecified) D83.9 Common Variable Immunodeficiency G35 MS (Relapsing Remitting) G61.0 GBS G61.81 CIDP G61.89 MMN G70.00 MG without acute exacerbation G70.01 MG with acute exacerbation
M33.20 Polymyositis M33.90 Dermatomyositis Other Code: _________________ Description: _______________________________
For additional ICD-10 information, please visit www.CVSspecialty.com/ICD10 Patient Clinical Information: Allergies: _____________________________ Weight: __________________ lb/kg Height: _______________________ in/cm Lab Orders: _________________________________________________________________________________________________________________ Nursing: Please arrange nursing for administration Patient may be taught to self-infuse
�PRESCRIPTION INFORMATION MEDICATION ROUTE DOSE/STRENGTH DIRECTIONS QUANTITY REFILLS
Immune Globulin ______________________
SC IV IM
________ grams ________ mg/kg
1 month 3 months ________
1 year _____
Normal Saline D5W IV
3 mL 5 mL _____________
Before and after infusion _________________________________________
1 month 3 months ________
1 year _____
Heparin 10 units/mL Heparin 100 units/Ml IV
3 mL 5 mL _____________
After infusion _________________________________________
1 month 3 months ________
1 year _____
Diphenhydramine PO IV IM
25 mg 50 mg _____________
Pre-Med: _________________________________ PRN Allergic Reaction: ______________________
_________________________________________ _________________________________________
With each infusion ________
1 year _____
Acetaminophen PO 325 mg 500 mg 650 mg 1 gm _____________
Pre-Med: _________________________________ _________________________________________
With each infusion ________
1 year _____
Epinephrine IM SQ
Adult 1:1000, 0.3 mL (>30kg/>66lbs) Peds 1:2000, 0.3 mL
(15-30 kg/33-66 lbs)
PRN Anaphylaxis Repeating Dose: __________________________
_________________________________________
Once ________
1 year _____
Other: ____________
Vascular Access Method peripheral central other _______________________________________ Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration zx___________________________________ x___________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)
Phone: 1-866-899-1661Fax Referral To: 1-866-843-3221Email Referral To: [email protected]
Caremark OnlyIGIV
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
x_________________________________________ x__________________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)
Phone: 1-866-899-1661Fax Referral To: 1-866-843-3221Email Referral To: [email protected]
Caremark OnlyIGIV
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
x_________________________________________ x__________________________________________ PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN (Date)