Refferal – apex

Complete the form below and attach signed orders, current labs, history and physical, then click submit. We’ll review at our earliest convenience and contact you to confirm acceptance of service. You can also call us toll-free at 877-501-6800 to start the referral process.

Patient Information

Last Name *

First Name *

SSN *

Date of Birth *

Sex *

Address *

City *

State *

Zip *

Physician Information

Ordering Physician *

Phone *

License Number *

DEA *

Address *

City *

State *

Zip *

Rx: Intravenous Route

Choose an IVIG course:

IVIG grams daily for day(s).

IVIG grams/kilogram daily given over non-consecutive day(s).

Repeat course every week(s) for a total of course(s). OK to round dose to nearest vial size.

Rx: Subcutaneous Route

Choose an SQIG course:

SQIG grams each month given as dose.

SQIG grams times per month.

Administer SQIG using sites at a time. Repeat week(s). OK to round does to nearest vial size.

Refill x 1 year. If needed, a Basic Metabolic Panel (Chem7) to be drawn prior to first dose. If ncessary Patient may have first dose administered in the home by a skilled nurse, unless instructed otherwise. Anaphylaxis kit per protocol, refill x 1 year.

Special Instructions

Referral Attachments Orders, Patient Information and History & Physical

Please combine multiple documents into a single PDF (watch a guide) or ZIP file (watch a guide).

Physician Name: *

DEA#: *

Date: *

Physicians Signature: I certify that the use of the indicated treatment is medically necessary and I will be supervising the patient’s treatment. *

THE FOLLOWING INFORMATION IS IMPORTANT TO EXPEDITE THE AUTHORIZATION PROCESS:

- Immunoglobulin order: included dose, route of administration, frequency, duration, and any premedications OR use Rx order section above.
- Patient demographis: include insurance information. We will obtain authorization unless the insurance dictates otherwise.
- H & P OR progress note(s) describing diagnosis and clinical status.
- Labs: BUN/Creatinine (preferred with in last 90 days) and IgA.

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