Cimzia (Certolizumab pegol)

Cimzia Order Form

(Certolizumab pegol)
Referral Order Type
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

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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
Format: (000) 000-0000.
Contact Email
Contact Fax
Format: (000) 000-0000.
Diagnosis
ICD-10 Primary Diagnosis Code
ICD-10 Primary Diagnosis Code
(Optional) ICD-10 Secondary Diagnosis Code
Medication Orders
Initial/Reload Dosing: mg injection on day 0, 2 weeks, 4 weeks, then every weeks.
Maintenance Dosing: mg injections every weeks.
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
Was patient treated for positive TB screening result?

Other
Hepatitis-B Panel Date

MonthDayYear
Hepatitis-B Panel Result
Cocci/Valley Fever Screening Date

MonthDayYear
Cocci/Valley Fever Screening Result
Was patient treated for Cocci/Valley Fever?

Other
Hepatitis-C Panel Date

MonthDayYear
Hepatitis-C Panel Result
Was patient treated for Hepatitis-C?

Other
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.

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Signature
Prescriber's Signature
Date

MonthDayYear
Should be Empty:

Cimzia Order Form

Patient Information

Patient's Insurance

Referring Physician

Diagnosis

Medication Orders

Required Documentation & Pre-Testing

Signature