Referal Form ⸻ Certolizumab 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 Active Ankylosing Spondylitis ICD 10 Code: M45.9 Active Axial Spondyloarthritis ICD 10 Code: M47.9 Active Psoriatic Arthritis ICD 10 CODE: L40.52 Moderate to Severe Plaque Psoriasis ICD 10 CODE: L40.0 Moderate to Severe Crohn’s Disease ICD 10 CODE: K50.90 Other: ICD 10 Code: Moderate to Severe Rheumatoid Arthritis ICD 10 CODE: M06.9 Has the patient had failure or contraindication to at least 12 weeks of at least one DMARD? YESNO REQUIRED DOCUMENTATION This signed order form by the provider Clinical/Progress notes Patient demographics AND insurance information Labs and Tests supporting primary diagnosis Hepatitis B Test Results: HBsAg, Total HepB Core Antibody TB Test Results List Tried & Failed Therapies, including duration of treatment: 1) 2) MEDICATION ORDERS** Dosing Please indicate frequency in blank space provided. Cimzia 200mg SubQ Cimizia 400mg SubQ Other: Cimzia mg. SubQ 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 cup.
