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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
Cimzia Order Form
Δ
Select Location
(Required)
Charleston
Bluffton
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)
M05.79 RA with rheumatoid factor of multiple sites w/o organ involvement
L40.5__ Psoriatic arthropathy
M06.09 RA w/o rheumatoid factor, multiple sites
M45.9 Ankylosing spondylitis, unspecified site in spine
M45.A6 Non-radiographic axial spondylarthritis of lumbar region
K50__ Crohn’s Disease
L40.0 Plaque psoriasis
L40.0 Plaque psoriasis
L40.5__ Psoriatic arthropathy
(Required)
Indication (Other)
Dose
(Required)
With Loading Doses: 400mg SQ at weeks 0, 2 and 4 then every 4 weeks – Crohn’s
With Loading Doses: 400mg SQ at weeks 0, 2 and 4 then 200mg every 2 weeks – RA, PsA
400mg SQ every other week – plaque psoriasis
Maintenance Only: 400mg SQ every 4 weeks
Maintenance Only: 200mg SQ every 2 weeks
Dose (additional note)
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
Other
Most Recent Labs (OTHER)
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
(Required)
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
