Actemra (Tocilizumab) Referral to Valley Infusion Care

Actemra Order Form

tocilizumab
Referral Order Type*

New ReferralChange Order (Medication Change)Restart TreatmentContinuing Treatment
Patient Information
Name*

First NameLast Name
Date of Birth

MonthDayYear
Patient Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Insurance
Upload Patient's Insurance Card, if available

Cancelof
Primary Insurance Carrier*
Primary ID #*
Secondary Insurance Carrier
Secondary ID #
Referring Physician
Practice Name
Provider Name*
NPI #*
TIN #*
Tax ID
Provider Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name*
Contact Phone*
Contact Email
Contact Fax*
Diagnosis
ICD-10 Primary Diagnosis Code*
ICD-10 Primary Diagnosis Code*
(Optional) ICD-10 Secondary Diagnosis Code
Prescription
Pre-Medication

Diphenhydramine 25mg IVDiphenhydramine 50mg IVMethylprednisolone 125mg IV pushMethylprednisolone 100mg IVOther
Patient Weight
Weight
kg
Initial Dose (IV)
Administer
mg/kg
every
weeks
for
total doses
Maintenance Dose (IV)
Administer
mg/kg
every
weeks
refills
Alternative Dose or Other Instructions
Dosing or Instructions
Required Documentation & Pre-Testing

Patient Demographic Sheet, Copy of most recent office & consult notes (must include prescribed drug discussion); If continuation of treatment, include last infusion note; Current Medication List
TB Screening Date*

MonthDayYear
TB Screening Result*

NegativePositive
Was patient treated for positive TB screening result?*

YesNoOther
Hepatitis-B Panel Date*

MonthDayYear
Hepatitis-B Panel Result*

NegativePositive
Cocci/Valley Fever Screening Date*

MonthDayYear
Cocci/Valley Fever Screening Result*

NegativePositive
Was patient treated for Cocci/Valley Fever?*

YesNoOther
Hepatitis-C Panel Date*

MonthDayYear
Hepatitis-C Panel Result*

NegativePositive
Was patient treated for Hepatitis-C?*

YesNoOther
Upload Most Recent office & consult notes (must include discussion of prescribed drug)*

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Current Medication List & Labs*

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If continuing treatment, most recent infusion note.*

Cancelof
Signature
Prescriber's Signature

Clear
Date*

MonthDayYear
Should be Empty:

Actemra Order Form

Patient Information

Patient's Insurance

Referring Physician

Diagnosis

Prescription

Required Documentation & Pre-Testing

Signature