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Refer A Patient
FIND A LOCATION
REFER A PATIENT
Conditions We Treat
How We Work
Referral Process
For Patients
What To Expect
FAQs
Blog
Contact Us
Refer A Patient
Actemra Order Form
Δ
Select Location
(Required)
Charleston
Bluffton
Knoxville
Sandy Springs
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
New Start | Maintenance
(Required)
New Start
Maintenance
Last Dose Given
(Required)
Referring Office
(Required)
Contact Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Direct Phone for Contact
(Required)
Fax
(Required)
Patient Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Allergies
(Required)
Allergies
NKDA
Allergies
(Required)
Height
(Required)
Weight
(Required)
Indication
(Required)
MO5.__ Rheumatoid Arthritis
MO6.__ Rheumatoid Arthritis w/o rheumatoid factor
M31.__ Giant Cell Arteritis
Other
Indication (Other)
DRUG
(Required)
4mg/kg IV every 4 weeks
4mg/kg IV X 1 infusion then increase to 8mg/kg every 4 weeks
6mg/kg IV every 4 weeks – GCA
8mg/kg IV every 4 weeks
Other
Drug (Other)
Premedication Orders (not required by PI)
Acetaminophen po
Diphenhydramine
Solu-Medrol:
Other
Premedication Orders (Other)
Acetaminophen
1000mg PO
500mg PO
30min prior to infusion
Diphenhydramine
25mg PO
50mg PO
25mg IVP
30min prior to infusion
Solu-Medrol
62.5mg IVP
100mg IVP
Other
30min prior to infusion
Solu-Medrol (Other)
Prescriber Name
(Required)
Title
(Required)
NPI
(Required)
DEA
(Required)
Date of Order
(Required)
MM slash DD slash YYYY
Referrals will not be processed untill we receive ALL the following:
(Required)
Face Sheet / Patent Demographics
Insurance card(s) – copy of front & back
Last 2 clinic notes pertaining to referring diagnosis (include ALL past & failed therapy outcomes)
Most Recent Labs (within last 4-8 weeks) – Required:
(Required)
CBC
CMB
Lipids
TB (within the past 3 years)
Hep B
Other
Most Recent Labs (OTHER)
(Required)
Demographic and insurance information
(Required)
Max. file size: 300 MB.
Necessary lab results as needed by drug protocol
(Required)
Max. file size: 300 MB.
Office notes that support the medical necessity for infusion therapy
Office notes that support the medical necessity for infusion therapy
(Required)
Max. file size: 300 MB.
* Required
Office notes that support the medical necessity for infusion therapy
Contact information for referring provider
Referrer Provide Name
(Required)
Referrer Practice Name
(Required)
Referrer Address
(Required)
Referrer Phone
(Required)
Referrer Fax
(Required)
Nursing Oders
Start PIV/Access CVC (CXR confirmation required)
Flush device per Ascend flushing procedures
Provide nursing care per Ascend Infusion Nursing policies and procedures
Provide acute care for infusion reactions following protocol orders which can be located on our website
