Referal Form ⸻ Actemra PATIENT INFORMATION Name: DOB: Allergies: Date of Referral: REFERRAL STATUS New ReferralDose or Frequency ChangeOrder Renewal INFUSION OFFICE PREFERENCES (Optional) Preferred Location*: *List of infusion center locations may be found at: https://metroinfusioncenter.com/infusion-center-locations/ Please note: Requests will be accommodated based on infusion center availability and are not guaranteed. DIAGNOSIS AND ICD 10 CODE Rheumatoid Arthritis ICD 10 Code: M06.9 Systemic Juvenile Idiopathic Arthritis (SJIA) ICD 10 Code: M08.09 Polyarticular Juvenile Idiopathic Arthritis (PJIA) ICD 10 Code: Other: ICD 10 Code: REQUIRED DOCUMENTATION This signed order form by the provider Clinical/Progress notes Patient demographics AND insurance information Labs and Tests supporting primary diagnosis TB Test Results List Tried & Failed Therapies, including duration of treatment: 1) 2) 3) MEDICATION ORDERS** Rheumatoid Arthritis Dosing Actemra 4mg/kg IV every 4 weeks Actemra 8mg/kg IV every 4 weeks Actemra Please note that doses 800mg for RA are not recommended. SJIA Dosing Actemra 12mg/kg IV every 4 weeks (for patients weighing <30kg) Actemra 8mg/kg IV every 4 weeks (for patients weighing ≥ 30kg) PJIA Dosing Actemra 10mg/kg IV every 4 weeks (for patients weighing <30kg) Actemra 8mg/kg IV every 4 weeks (for patients weighing ≥ 30kg) Patient Weight: Refills: X 6 monthsX 1 yearOther PRESCRIBER INFORMATION Prescriber Name: Office Phone: Office Fax: Office Email: Prescriber Signature: Date: All information contained in this order form is strictly confidential and will become part of the patient's medical record. Contact us with questions at: (877) 448-3627 Fax Completed Form and all documentation to: 866-507-1164 Please prove you are human by selecting the key.
