MULTIVITAMIN THERAPY REFERRAL FORM

FAX: 718-676-9111
Phone: 855-444-3979
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:
PATIENT EVALUATION
  
  
         Date of negative positive TB Test:
DIAGNOSIS
CURRENT PATIENT MEDICATIONS
PRESCRIPTION INFORMATION

Solution ( Select one)

Additive ( Select one)

Duration and Frequency

Solution ( Select one)

Sodium Chloride 0.9%:
Dextrose 5%:
D5 NS:
D5 1/2 NS:
Ringers Lactate:
D5 RL:

Additive ( Select one)

Duration and Frequency

hours
mL/hr
NURSING: Required Placement      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 and utilizing our services, you are authorizing Home Infusion Group, Inc. and it’s employees to serve as your authorization designated agent in dealing with medical and prescription insurance companies.
Prescriber Signature:
(no stamps)
Date:
(required)
Security code