Home Infusion Group
Patient Information

Patient Name:

Home Address:

City, State, Zip:

Home Phone:

Cell Phone:

SS:

Date of Birth: Gender: Male Female

Contact Person:

Prescriber Information

Prescriber Name:

Home 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
Crohn's Disease
Ulcerative Colitis
Prior Therapy (Yes No )

Crohn's Disease

K50.00 Crohn’s of Small Intestine
K50.10 Crohn’s of Large Intestine
K50.80 Crohn’s of Small & Large Intestine
K50.90 Crohn’s Disease
Other:

Ulcerative Colitis

K51.0 Ulcerative Pancolitis
K51.2 Ulcerative Proctitis
K51.3 Ulcerative Rectosigmoiditis
K51.5 Left Sided Colitis
K51.8 Other Ulcerative Colitis
K51.9 Ulcerative Colitis Other:

Prior Therapy (Yes No )

MTX                  Azathioprine
Corticosteroid   6-MP
Sulfasalazine     NSAID’s
BIOLOGICs:
  Start Date:
  End Date:  
PATIENT EVALUATION

Patient Weight:      Height:      Allergies:  
Does patient have any active Infection? Yes No       Date of negative positive   TB Test:

PRESCRIPTION INFORMATION
Medication Dose and Strength Directions Quantity Refills
Cimzia© (Certolizumab) Cimzia Starter kit
200mg Vial
Induction Dose:400mg SC on Day 1 and at weeks 2 and 4
Maintenance Dose:Inject 400 mg SC ervery 4 weeks
days
weeks
Entyvio© (Vedolizumab) 300mg single dose vial
in 250 mL of 0.9% NS
Induction Dose: 300mg IV at week 0, week 2, and week 6
Maintenance Dose: 300mg IV every 8 weeks
days
weeks
Humira© (Adalimumab) 40 mg Starter pack
20 mg
40 mg Syringe
Induction Dose: 160mg SC on Day 1, then 80 mg on Day 15
Maintenance Dose: 40mg SC every 2 weeks
days
weeks
Orencia© (Abatacept) 125 mg Syringe
250 mg Vials
125 mg SC once a week
Induction Dose: Infuse mg Day 1, week 2, and week 4
Maintenance Dose: Infuse mg every 4 weeks
days
weeks
Remicade© (Infliximab) 100mg / 20 ml vial in 250 mL of 0.9% NS Induction Dose: IV at 5mg/kg (Dose = mg) at 0, 2 and 6 weeks
Maintenance Dose: IV at 5mg/kg (Dose = mg) every 8 weeks
Other:
days
weeks
Simponi-Aria© (Golimumab) 50 mg/ml vial
100 mg/ml vial
Induction Dose: 200mg SC week 0, then 100 mg week 2
Maintenance Dose: Inject 100 mg SC every 4 weeks
days
weeks
Stelara© (Ustekinumab) 130 mg/26 ml vial Pts ≤55 kg: 260 mg as single dose
Pts >55 kg to 85 kg: 390 mg as single dose
Pts >85 kg: 520 mg as single dose
Maintenance Dose: Inject 90 mg SC every 8 weeks
days
weeks
Other Medications
PREMEDICATE: 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

   

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

         

Flush IV line after infusion

NURSING: Requires Placement PIV Midline IV Line for administration and nurse to administer infusion in home
Current IV Access:       Delivery Method:
Therapy Start Date: Length of Therapy: Pharmacy to coordinate home health nursing visit as necessary:
By signing this form you are authorizing Home Infusion Group to serve as your prior authorization designated agent in dealing with insurance companies.
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