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For Referring Providers

Infusion Order forms

Our infusion suite is equipped for medications and sub-Q injections of all types. Below are 5 of our most utilized ones. If you have questions or would like a different order form, please contact our office and we would be happy to send one to you, or you are always welcome to send your own. Our office will only contact you for more information if that is what the insurance is requesting for approval. 

Evenity Order form

You are welcome to use our order form or your own when requesting a medication for your patient in our infusion suite!

Xolair Order Form

Feel free to use our order form or an order from your clinic. We are happy to help you in anyway!

Prolia Order Form

*Often insurance will request recent lab work or even a bone scan prior to approval, our clinic will only ask if insurance requests*

Infusion Medication Order forms: Files

Referring your patient for an Infusion or Sub-Q injection

Information regarding what various insurance companies will request

Our team is always happy to help with any information needed in order for your patient to receive the medication you are ordering. Here are some helpful tips to getting those medications approved by your patient's insurance. 

  • If referring for Leqvio, Repatha, or any medication in this category - most insurance will want proof of medical necessity. In our experience what has been requested and then required for payment of medication is:, documentation that it is heterozygous familial hypercholesteremia OR, documentation of the Framingham Score, list of trialed and failed PCSK9 inhibitors, and a full lipid panel.  (within the last 60 days or less)

  • When ordering Prolia, Evenity and medications in this category - a DEXA scan is most often requested. 

  • Xolair, Nucala, Fasenra and Tezspire (and those in this category) most often require recent eosinophil levels and presence of IgE. 

Many insurances require different items in order to be deemed "medically necessary" and many require nothing up front, until it is time for them to pay - then it is requested. These items are not always required prior to the patient receiving the medication, however, some insurance companies will request AFTER the treatment has been given. These tips are intended for useful information, it is not always required prior to.  If you or your patient, have any questions, please do not hesitate to contact our clinic 907-864-0022

Infusion Medication Order forms: Headliner
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