Referal Form ⸻ Infliximab PATIENT INFORMATION Name: DOB: Allergies: Date of Referral: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 Moderate to Severe Ulcerative Colitis ICD 10 Code: K51.90 Moderate to Severe Crohn’s Disease ICD 10 Code: K50.90 Rheumatoid Arthritis ICD 10 Code: M06.9 Ankylosing Spondylitis ICD 10 Code: M45.9 Psoriatic Arthritis ICD 10 Code: L40.52 Plaque Psoriasis ICD 10 Code: L40.0 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 Hepatitis B Test Results: HBsAg, Total HepB Core Antibody TB Test Results List Tried & Failed Therapies, including duration of treatment: 1) 2) 3) MEDICATION ORDERS Initial Dosing Remicade 5mg/kg IV at week 0, 2, 6, then every 8 weeks thereafter Maintenance Dosing Remicade 5mg/kg IV every 8 weeks Alternative Dosing Remicade Weight = kg. Refills: X 6 monthsX 1 yearOther PREMEDICATIONS Acetaminophen 650mg PO prior to Remicade infusion Diphenhydramine 25mg PO prior to Remicade infusion Methylprednisolone 40mg Slow IV Push PRN infusion reaction Other: Please note: if an infusion reaction occurs, the on-call physician will order appropriate rescue medications as deemed medically necessary. This may also include pausing, reducing the rate of infusion or discontinuing the medication. 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 plane.
