Tysabri Order Form

G50.___Moderate to Severe Active Crohn’s

Premedication Orders (Other)

Methylprednisolone (Other)

Date of Order

Most Recent Labs (OTHER)

CAUTION: Observe patient during all infusions. Post-infusion, for the first 12 infusions, observe patient for one hour after the infusion is complete

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

Office notes that support the medical necessity for infusion therapy

Contact information for referring provider