IV Solutions RX Pharmacy SCIg Referral Form

IV Solutions RX SCIg Referral

5315 Avion Park Dr., Suite 120 Tampa, Florida 33607-1461
PATIENT INFORMATION
Patient Name

First NameLast Name
Sex

MaleFemale
SSN
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Phone Number Type

HomeCellWork
Alternate Phone Number
Alternate Phone Number Type

HomeCellWork
May we leave messages on the lines?

YesNoOther
May we text you?

YesNo
Weight
LB/KG

Pounds (Lb)Kilograms(Kg)
Height
IN/CM

Feet/Inches (In)Centimeters(Cm)
Emergency Contact

First NameLast Name
Emergency Contact's Phone Number
ICD-10
Diagnosis
INSURANCE INFORMATION
Insurance Card

Please upload images of the front and back of your patient's insurance card
Cancelof
Insurance
Company Name
ID #
Group #
Insured Party
Primary insured party
Additional Insurance
Alternate or Secondary Insurance
ID #
Alternate or Secondary Insurance
Group
Alternate or Secondary Insurance
Insured Party
Primary insured party, Alternate or Secondary Insurance
CLINICAL INFORMATION

Clinical notes, labs, test results, medication history, allergies
Previous IVIg/SCIg

YesNo
If yes, what were the previous products?
What dates were they on these medications?
Allergies

NKDAOther
PRESCRIPTION

Administration by manufacturer guidelines and per state law, prescriptions will be dispensed as generic unless otherwise noted.
SCIg
Pharmacist to select appropriate product and what is on formulary unless brand name is specified here
Dose: X# grams SC every week OR X # grams/kilogram per week. May be divided over 2 days if needed.
Dispense: 4 week supply for 1 year OR X # cycles.
PRE-MEDICATION PROTOCOL

Adults and pediatrics, please select all that apply
Diphenhydramine blanksmg 30 minutes before infusion. May repeat PRN up to every hours. PO capsule PO capsule12.5mg/5mL Chewable
Acetaminophen blanksmg 30 minutes before infusion. May repeat PRN up to every Number hours. PO tablet PO liquid 160mg/5mL Chewable tablet
Other blanks
Lidocaine 2.5% and Prilocaine 2.5% cream (EMLA) 30 grams topical, apply a small amount at insertion site 30-60 minutes prior to needle insertion.
ANAPHYLAXIS ORDERS AND MEDICATIONS:
1. Stop the infusion.

2. Call 911, then call Prescribing Physician and the Pharmacy (844-650-5802)
3.Epinepherine (auto-injector 2 pack): Administer IM for severe anaphylactic reaction, may repeat in 5-15 minutes IM x 1.

0.3MG (weight > 30kg)0.15MG for PEDIATRICS (weight 15-30kg)0.1 MG for PEDIATRICS (weight 7.5-15kg)
NURSING/SUPPLIES/EQUIPMENT:
NURSING: Nursing visits to train patient/car eprovider and subcutaneous immunoglobulin administratios, assess and monitor patient, and provide education. 1-4 skilled nursing visits for the purposes of subcutaneous SCIg administration independent of the nurse. PRN thereafter to assess and refresh skills.
SUPPLIES: Dispense medication and supplies necessary for infusion.
PUMP: Syringe Driver/Pump(s)

YesNo
PRESCRIBER OF RECORD
Prescriber

First NameLast Name
NPI
Tax ID
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
Contact Name

First NameLast Name
Phone
Fax
I authorize IV Solutions RX and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription or set of prescriptions and refills of the same prescription or set of prescriptions for the patient listed above. I understand that I can revoke the designation at any time by providing written notice to IV Solutions RX.

CONFIDENTIALITY NOTICE: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, disemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by replying by email at info@ivsolutionsrx.com and then destroying all copies of the original message.
Prescriber's Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

IV Solutions RX SCIg Referral

PATIENT INFORMATION

INSURANCE INFORMATION

CLINICAL INFORMATION

PRESCRIPTION

PRE-MEDICATION PROTOCOL

ANAPHYLAXIS ORDERS AND MEDICATIONS:

NURSING/SUPPLIES/EQUIPMENT:

PRESCRIBER OF RECORD