Ocrevus Order Form
(Ocrelizumab)
Referral Order Type
*
New Referral
Change Order (Medication Change)
Restart Treatment
Continuing Treatment
Patient Information
Name
*
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Patient Phone
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient's Insurance
Upload Patient's Insurance Card, if available
Browse Files
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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
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Name
*
Contact Phone
*
Contact Email
Contact Fax
*
Diagnosis
ICD-10 Primary Diagnosis Code
*
(Optional) ICD-10 Secondary Diagnosis Code
Medication Orders
Patient/Weight:
*
kg
Initial/Reload Dosing: 300mg Day 0, 300mg Day 14
Maintenance Dosing: 600mg every 6 months (Observe for 1 hour post-infusion)
Premeds:
diphenhydramine
APAP
IV methylprednisolone 100mg
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
*
-
Month
-
Day
Year
TB Screening Result
*
Negative
Positive
Was patient treated for positive TB screening result?
*
Yes
No
Other
Cocci/Valley Fever Screening Date
*
-
Month
-
Day
Year
Cocci/Valley Fever Screening Result
*
Negative
Positive
Was patient treated for Cocci/Valley Fever?
*
Yes
No
Other
Hepatitis-B Panel Date
*
-
Month
-
Day
Year
Hepatitis-B Panel Result
*
Negative
Positive
Hepatitis-C Panel Date
*
-
Month
-
Day
Year
Hepatitis-C Panel Result
*
Negative
Positive
Was patient treated for Hepatitis-C?
*
Yes
No
Other
Upload Most Recent office & consult notes (must include discussion of prescribed drug)
*
Upload Office Note/Consult Notes
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Current Medication List & Labs
*
Upload Current Medication List
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If continuing treatment, most recent infusion note.
*
Upload last infusion note (for continuation only)
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Signature
Date
*
/
Month
/
Day
Year
Prescriber's Signature
SUBMIT
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