Treatment Options
How We Work
Referral Process
Timeline
Support
For Patients
What To Expect
Conditions We Treat
FAQs
FIND A LOCATION
REFER A PATIENT
Treatment Options
How We Work
Referral Process
Timeline
Support
For Patients
What To Expect
Conditions We Treat
FAQs
Actemra Order Form
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
New Start | Maintenance
New Start
Maintenance
Last Dose Given
Referring Office
(Required)
Contact Name
(Required)
Date
MM slash DD slash YYYY
Direct Phone for Contact
(Required)
Fax
Patient Name
Date of Birth
MM slash DD slash YYYY
Allergies
Allergies
NKDA
Allergies
Height
Weight
Indication
MO5.__ Rheumatoid Arthritis
MO6.__ Rheumatoid Arthritis w/o rheumatoid factor
M31.__ Giant Cell Arteritis
Other
Indication (Other)
DRUG
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
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 po
1000mg
500mg
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
Title
NPI
DEA
Date of Order
MM slash DD slash YYYY
Referrals will not be processed untill we receive ALL the following:
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:
CBC
CMB
Lipids
TB (within the past 3 years)
Hep B
Other
Most Recent Labs (OTHER)
Demographic and insurance information
Max. file size: 300 MB.
Necessary lab results as needed by drug protocol
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
Max. file size: 300 MB.
Office notes that support the medical necessity for infusion therapy
Contact information for referring provider
Referrer Provide Name
Referrer Practice Name
Referrer Address
Referrer Phone
Referrer Fax
Actemra Order Form
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
New Start | Maintenance
New Start
Maintenance
Last Dose Given
Referring Office
(Required)
Contact Name
(Required)
Date
MM slash DD slash YYYY
Direct Phone for Contact
(Required)
Fax
Patient Name
Date of Birth
MM slash DD slash YYYY
Allergies
Allergies
NKDA
Allergies
Height
Weight
Indication
MO5.__ Rheumatoid Arthritis
MO6.__ Rheumatoid Arthritis w/o rheumatoid factor
M31.__ Giant Cell Arteritis
Other
Indication (Other)
DRUG
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
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 po
1000mg
500mg
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
Title
NPI
DEA
Date of Order
MM slash DD slash YYYY
Referrals will not be processed untill we receive ALL the following:
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:
CBC
CMB
Lipids
TB (within the past 3 years)
Hep B
Other
Most Recent Labs (OTHER)
Demographic and insurance information
Max. file size: 300 MB.
Necessary lab results as needed by drug protocol
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
Max. file size: 300 MB.
Office notes that support the medical necessity for infusion therapy
Contact information for referring provider
Referrer Provide Name
Referrer Practice Name
Referrer Address
Referrer Phone
Referrer Fax
