PATIENT INFORMATION

Patient 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

Autoantibody-Positive, Systemic Lupus Erythematosus (SLE)	ICD 10 Code: M32.9
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
Pregnancy Test (if applicable)	ANA (anti-nuclear Ab) and/or anti-dsDNA Test Results
List Tried & Failed Therapies, including duration of treatment:
1) 2)

MEDICATION ORDERS**

Initial dosing	Benlysta 10 mg/kg IV at Week 0, 2, 4 then every 4 weeks thereafter**
	Benlysta
Maintenance Dosing	Benlysta 10mg/kg IV every 4 weeks**
	Benlysta
Patient Weight:
**Patient weight required for weight-based orders.
Refills:	[RefillsDoses]	[otherDoses]

PREMEDICATIONS

Acetaminophen 650mg PO, 30-60 minutes prior to Benlysta infusion
Diphenhydramine 25mg PO, 30-60 minutes prior to Benlysta infusion (recommended by manufacturer)
Methylprednisolone 100mg Slow IV Push PRN infusion reaction
Other

OTHER TESTING (Optional)

Urine pregnancy test prior to first infusion

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
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