Treatment Options
How We Work
Referral Process
For Patients
What To Expect
Conditions We Treat
FAQs
News
Contact Us
FIND A LOCATION
REFER A PATIENT
Treatment Options
How We Work
Referral Process
For Patients
What To Expect
Conditions We Treat
FAQs
News
Contact Us
Cimzia 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
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
Indication (Other)
Dose
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
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
CMP
TB
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
