Phone: 866.506.2626 • Fax: 800.696.0607
Date Shipment Needed: Ship To: Patient Prescriber
Nursing needed; Training needed
All the supplies including syringes and needles will be dispensed if needed.
IVIG HOM
E INFUSION REFERRAL FORM
PATIENT INFORMATION
Patient Name: DOB: Sex: M F Weight: lbs. kg.
SSN:
Phone: Allergies:
Address: City: Sta
te: Zip:
Emergency Contac
t: Phone: Please attach demographic informa
tion
PRESCRIBER INFORMATION
Prescriber: NPI: DEA: State Lic:
Supervising P
hysician: Practice Name:
Address: City: State: Zip:
Phone: Fax: Key Office Contact: Phone:
D
IAGNOSIS INFORMATION / MEDICAL ASSESMENT
_
_____________________________________
_____________
Page 1 of 1
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Primary Diagnosis, choose one:
Guillian-Barre Syndrome
CIDP & Immune Neuropathies with Paraprotenemia
Immune Neuropathy other than CIDP without Paraproteinemia
CIDP
Vasculitic Neuropathy
CVID
Multifocal Motor Neuropathy
Myasthenia Gravis
Lambert-Eaton Myasthenic Syndrome
Polymyositis
Dermatomyositis
Diabetic Proximal Neuropathy
Others
Does patient already have a line? Yes No If yes, type of line _
______________________________________________________________
____________________IVIG to be infused via the existing line: Yes No
First IVIG Infusion: Yes, if yes, IgA level is more than 5 mg/dl:
Yes No Not Available Ig Quantitation: IgA, IgG, IgM (prior to 1
st
IVIG infusion)
No, if no, brand/dose of IVIG: ________________________________________Last infusion Date:
Note: IVIG contains IgA and is contraindicated in IgA deficient patients with antibodies against IgA and history of hypersensitivity.
______________________________________
INSURANCE INFORMATION
Please attach front and back of patient’s insurance card (medical and prescription)
COPAY CARD ENROLLMENT
Please check if enrolling in copay card Copay ID:
PRESCRIPTION INFORMATION
IVIG (IV Immunoglobulin) Order: ____________________________________________________________________________________________________________________
*Will choose the IVIG brand if not specified
IVIG dose: ________ grams/kg = grams (rounded to the nearest vial size) infuse intravenously ________
Range: 0.2-2 grams/kg)
Repeat dose daily x ________ consecutive days total, repeat dose: Monthly x ________ months Other: _______________________
Repeat dose weekly x ________ weeks total
Repeat dose monthly x ________ months total
Other: ___________________________________________________________________________________________________________________________________
Suggested Rate of Infusion:
30-150 mL/hr as tolerated by patient (increase rate gradually every 30 minutes by 20-30 mL/hr)
Other: ___________________________________________________________________________________________________________________________________
Pre-Medications: To be Administered 30 Minutes Prior to IVIG Infusion (QTY: Per Infusion)
Diphenhydramine 25-50 mg PO, dispense #2 (25 mg)
Acetaminophen 650 mg PO, dispense #2 (325 mg)
Other: ___________________________________________________________________________________________________________________________________
Procedure for Anaphylaxis
STOP infusion and call MD and 911
Diphenhydramine 25-50 mg IVP every 4 hours prn (rate to not exceed 25 mg/min.)
QTY:
Refills:
Epinephrine (1:1000) 0.4 mg SQ prn anaphylaxis, may repeat every 20 minutes x 2
QTY: 3 amp
Refills:
________________________________________________________________________________________________________ Other:
QTY:
Refills:
Supplies for Infusion
NaCl 0.9%/ D5W for flush: flush Line/Port with (3 – 5 mL for PIV and 5-10 ml for Central line/Port) per nursing agency protocol
(NaCl 0.9% or D5W will be used based on IVIG compatibility)
QTY: QS
Refills:
Heparin for flush (100 Unit
s/ml) (if RN keeps PIV or if needed for Central Line), flush with 3 – 5 ml per nursing agency protocol
QTY:
Refills:
Sterile water for reconstitution of powder to make the requested concentration (for Carimune NF)
QTY:
Refills:
________________________________________________________________________________________________________ Other:
QTY:
Refills:
Prescriber’s Signature:
DAW (Dispense as Written) Date:
Prescriber certifies that this referral form contains an original signature and is signed by the treating prescriber. NO STAMPED SIGNATURES WILL BE ACCEPTED. Where required by law, send electronic prescription or on
official state prescription blank. In the event requested agent is not available through AcariaHealth, this prescription shall be forwarded to an eligible pharmacy.
IMPORTANT NOTICE: This message may contain privileged and confidential information and is intended only for the individual named. If you are not the named addressee, you should not disseminate, distribute or copy this fax. Please notify the sender
immediately if you have received this document by mistake, then destroy this document. Please direct all verification or notification to AcariaHealth or any of its subsidiaries using the contact information provided on this coversheet.
Rev: 1.28.21
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