company logo IVIg / SCIg
REFERRAL FORM
FAX: 718-676-9111
Phone: 718-676-9070
Email: welcome@higny.com
Patient Information

Patient Name:

Address:

City, State, Zip:

Home Phone:

Cell Phone:

SS:

Date of Birth:

Gender: Male Female

Contact Person:

Prescriber Information

Prescriber Name:

Address:

City, State, Zip:

Phone:

Fax:

DEA:

License Number:

NPI Number:

INSURANCE INFORMATION (Please attach the front and back of insurance and prescription drug card)
Primary Insurance: ID #: Group:
Secondary Insurance: ID #: Group:
Prescription Card: ID #: BIN: PCN: Group:
DIAGNOSIS

Primary Immune Deficiency – specify Code:

D83.9 Common Variable Immunodeficiency(CVID)

D50.1 Hypogammaglobulinemia

G35 Multiple Sclerosis

G60.9 Multifocal Motor Neuropathy

G61.81 Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)

G70.01 Myasthemia Gravis

D69.3 Idiopathic Thrombocytopenic Purpura (ITP)

Other

PATIENT EVALUATION

Has patient previously received IVIG Yes No

Patient Current Weight:
Height:


Allergies:

PRESCRIPTION INFORMATION
Medication Directions (Route / Frequency / Length of Infusion) Quantity (Grams) Refills
Intravenous Immune Globulin
Gammaked 10%
Gamunex-C
Octagam 10%
Privigen 10%
Gammagard 10% Liquid
FIebogamma 5% DIF
Gammaplex 5%
Other:
Subcutaneous Immune Globulin
Hizentra 20%
Gammagard 10% Liquid
Gamunex - C
Other Medications
PREMEDICATE WITH: Diphenhydramine (Benadryl) mg
PO Inj.
APAP (Tylenol) mg
PO
Other
PRN for Anaphylactic Reaction: Hydrocortisone 100mg IV Push Epinephrine 0.3mg IM    Sodium Chloride 0.9%
250 ml 500 ml

Sodium Chloride 0.9% Flush

3 ml

5 ml

10 ml

20 ml

30 ml

and Flush IV line before and after infusion


Heparin Flush 10 units/ml

3 ml

5 ml

       

Heparin Flush 100 units/ml

3 ml

5 ml

       

and Flush IV line after infusion

NURSING: Requires Placement PIV Midline IV Line for administration and nurse to administer infusion in home

IV Access: PIV PICC Midline PORT Other # of Lumens Delivery Method: Gravity Infusion Pump

Therapy Start Date: Length of Therapy: Pharmacy to coordinate home health nursing visit as necessary: Yes No

By signing this form you are authorizing Home Infusion Group to serve as your prior authorization designated agent in dealing with insurance companies.
Prescriber Full Name:
(required)
Date:
(required)
Security code