Xolair (Omalizumab)

Xolair Order Form

(Omalizumab)
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

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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*
Contact Email
Contact Fax*
Diagnosis
ICD-10 Primary Diagnosis Code*
ICD-10 Primary Diagnosis Code*
(Optional) ICD-10 Secondary Diagnosis Code
IgE Level*
Medication Orders
Dosing:

375mg300mg225mg150mg
Frequency:

SC every 2 weeksSC every 4 weeks
o Other blanks
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
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

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Date*

MonthDayYear
Should be Empty:

Xolair Order Form