Conditions We Treat
How We Work
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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
News
Contact Us
Refer A Patient
Briumvi Order Form
Select Location
(Required)
Charleston
Bluffton
First Name
(Required)
Last Name
(Required)
Email Address
(Required)
New Start | Maintenance
(Required)
New Start
Maintenance
Last Dose Given
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)
G35.A__Relapsing Remitting Multiple Sclerosis
G35.C1__Secondary Progressive Multiple Sclerosis
G36.9.__ Clinically Isolated Syndrome
Other
Indication (Other)
Dosage Orders
(Required)
Induction:
150mg
IV on Day 1 then 450mg IV on Day 15
Maintenance: 450mg IV every 24 weeks after 1st infusion
Other
Dosage Orders (Other)
Premedication Orders (not required by PI)
(Required)
Acetaminophen
Diphenhydramine
Methylpredisolone
Other
Premedication Orders (Other)
Acetaminophen po
(Required)
1000mg
500mg
30min prior to infusion
Diphenhydramine
(Required)
25mg PO
50mg PO
25mg IVP
30min prior to infusion- REQUIRED
Methylpredisolone
(Required)
62.5mg IVP
100mg IVP
Other
30min prior to infusion – REQUIRED
Methylpredisolone (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
CMP
TB
Hep B
Alkaline Phosphatase (ALP)
Bilirubin
Quantitative Serum Immunoglobulin
Other
Most Recent Labs (OTHER)
CAUTIONS: Observe patient for at least 1 hour after first 2 infusions
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.
Office notes that support the medical necessity for infusion therapy
(Required)
Contact information for referring provider
Referrer Provide Name
Referrer Practice Name
Referrer Address
Referrer Phone
Referrer Fax
