RHEUMATOLOGY
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/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
Actemra© (Tocilizumba) 162mg PF Syringe
20mg/ml Vial
Pts ≤ 100Kg: 162 mg SC every other week (Max=162 mg SC every week)
Pts ≥ 100 Kg: 162 mg SC once a week
(4mg/kg) every 4 weeks, up to 8 mg/kg (Max=800mg)
days
weeks
Cimzia© (Certolizumba) Cimzia Starter Kit
200mg/ml Vial
Induction Dose: 400mg SC on Day 1 and at weeks 2 and 4
Maintenance Dose: Inject 200 mg SC every other week
Maintenance Dose: Inject 400 mg SC every 4 weeks
days
weeks
Enbrel© (Etanercept) 50 mg Syringe
50 mg Sure-click
50mg SC once a week
50mg SC twice a week (Max duration 3 months)
days
weeks
Humira© (Adalimumab) 40 mg Syringe/Pen
20 mg Syringe
40mg SC every other week (Induction Dose: 80 mg x1, for PsA)
Other:
days
weeks
Orencia© (Abatacept) 125mg Syringe
250mg Vials
125mg 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 / 20ml 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) 50mg/ml vial
100mg/ml vial
Intravenous: 2mg/kg IV at week 0, week 4 then every 8 weeks
SubQ: 50mg once a month (in combination with methotrexate)
days
weeks
Other:              
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

         

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:
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