Submit a Referral
Use the drug forms below to submit a referral for review by an Ascend Infusion referral coordinator. For each patient, we require:
- Demographic and insurance information
- Completed and signed order
- Necessary lab results as needed by drug protocol
- Office notes that support the medical necessity for infusion therapy
- Contact information for referring provider (provider name, practice name, address, phone, and fax)
- Fill out the online form below OR if you prefer to fax your order, please complete and print the needed form from the list below and fax over to 843.793.6181
Once approved, we will add the documentation and order to the patient’s EMR.
