Home Infusion Group
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 card)
Primary Insurance: ID #: Group:
Secondary Insurance: ID #: Group:
Prescription Card: ID #: BIN: PCN: Group:
DIAGNOSIS/ ICD 10 CODE
PRIOR FAILED MEDICATIONS
PATIENT EVALUATION

Patient Weight: Height: Allergies:  
Does pt. have active Infection? No Yes       Date of negative positive   TB Test:     Is the pt. currently on Methotrexate? Yes No

PRESCRIPTION INFORMATION
Medication Dose and Strength Directions Quantity Refills
Enbrel© (Etanercept) 50mg Syringe
50mg Sure-click
Initial Dose: 50mg SC twice weekly (Total duration 3 months)
               Other:
Maintenance Dose: 50mg SC once a week
days
weeks
Humira© (Adalimumab) Psoriasis Starter
40 mg Syringe
40 mg Pen
80mg SC Initial dose, then 40mg every other week beginning 1 week later
40mg SC every other week
Other:
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
Stelara© (Ustekinumab) 45 mg Syringe
90 mg Syringe
For Pt ≤ 100kg , administer:
Initial dose of 45mg SC at week 0 and week 4 , followed by every 12 week
For Pt > 100kg , administer:
Initial dose of 90mg SC at week 0 and week 4, followed by every 12 weeks
days
weeks
Other
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 after infusion


Heparin Flush 10 units/ml

3 ml

5 ml

and Flush IV line after infusion


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 Line: 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.
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