IVIG (Immunoglobulin) ORDER FORM

Fax To: 301-424-3590

Have a Question? Call: 240-514-5000

IVIG (Immunoglobulin) ORDER FORM

REFERRAL TYPE

o New Referral

o Order Renewal

o Restart

o Frequency Change

o Dosage Change

PREFERRED LOCATION

o 2730 University Blvd. West | Suite 714

o 14995 Shady Grove Road | Suite 250

o 5454 Wisconsin Avenue | Suite 600

Wheaton, MD 20902

Rockville, MD 20850

Chevy Chase, MD 20815

o 18111 Prince Philip Drive | Suite 323

o 71 Thomas Johnson Drive

o 2021 K Street, NW | Suite 300

Olney, MD 20832

Frederick, MD 21702

Washington, DC 20006

PATIENT INFORMATION

Name:

DOB:

Email:

Address:

Weight:

Phone:

KG

LBS

REFERRING PHYSICIAN INFORMATION

Name:

NPI:

Office Contact Name:

Phone:

Fax:

Address:

IVIG ORDER

Dosing/Frequency:

Diagnosis:

o D69.3¡ªImmune thrombocytopenic purpura

o D80.1¡ªNonfamilial hypogammaglobulinemia

o D83.0¡ªCommon variable immunodeficiency with predominant abnormalities of B-cell numbers and function

o G61.0¡ªGuillain-Barre syndrome

o G61.81¡ªChronic inflammatory demyelinating polyneuritis

o G61.89¡ªOther inflammatory polyneuropathies

o G70.00¡ªMyasthenia gravis w/o (acute) exacerbation

o G73.7¡ªMyopathy in diseases classified elsewhere

o M33.12¡ªOther dermatomyositis with myopathy

o M33.19¡ªOther dermatomyositis with other organ involvement

o M33.22¡ªPolymyositis with myopathy

o Other Diagnosis:

ICD-10 Code (Required):

Special Instructions:

Physicians Signature:

Date:

(Order is Valid for One Year)

REQUIRED DOCUMENTATION

Please fax the following documents and records:

¡ñ Patient Demographics

¡ñ Two most recent office notes (Supporting the DX and treatment ordered)

¡ñ Most recent labs that include values for:

¡ñ CMP

¡ñ IgA, IgG, IgM

¡ñ Copy of the patient¡¯s insurance card(s) ¨C front and back

¡ñ Medication History

¡ñ For continuation of treatment, include the last infusion note

We will contact the patient and schedule their treatment once our benefit investigation

and any prior authorizations have been completed.

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