Tepezza Order Form - Ascend Infusion Centers

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

Direct Phone for Contact(Required)

Fax

Patient Name

Date of Birth

Allergies

NKDA

Allergies

Height

Weight

Indication (ICD-10-CM):

TED E05.00

Other

Indication (Other)

DOSAGE ORDERS:

Loading dose: 10mg/kg IV x 1 dose

Maintenance: 20mg/kg IV every 3 weeks for 7 additional infusions

Other

DOSAGE ORDERS (Other)

Premedication Orders

Acetaminophen

Diphenhydramine

Methylprednisolone

Other

Premedication Orders (Other)

Acetaminophen

1000mg PO

500mg PO

30min prior to infusion

Diphenhydramine

25mg PO

50mg PO

25mg IVP

30min prior to infusion

Methylprednisolone

62.5mg IVP

125mg IVP

Other

30min prior to infusion

Methylprednisolone (Other)

Prescriber Name

Title

NPI

DEA

Date of Order

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

Hep B

Thyroid panel

Hearing test: before, during, and after treatment

Other

Most Recent Labs (OTHER)

DISCLAIMER: Referring provider attests to assess patients for elevated BGL and symptoms of hyperglycemia prior to infusion and will continue to monitor while on treatment. Referring provider will ensure patients with hyperglycemia or preexisting diabetes are under appropriate glycemic control before and while receiving Tepezza

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

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