Submit an order form by fax or email
Download and print the therapy-specific order form below.
You can fax or email the completed form, along with supporting clinicals.
You can email or fax directly to your Local Infusion center, fax numbers for each location can be found on the therapy-specific forms below, as well as on our Locations page.
Hate faxing? You can also submit a digital order form and eSign. We'll send you a copy for your records.
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Actemra
Download Actemra order form here.
Required clinicals:
- Negative TB within 1 year
- Absolute neutrophils, platelets, liver function test, lipid panel
- For RA- Rheumatoid factor, anti-CCP, CRP, ESR
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Amvuttra
Download Amvuttra order form here.
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Benlysta
Download Benlysta order form here.
Required clinicals:
- Positive autoantibodies indicative of SLE (e.g. ANA, anti-ds DNA, anti-Sm, anti-Ro/SSA, anti-La/SSB)
- Documentation that pt currently receiving standard therapy
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Boniva
Download Boniva order form here.
Required clinicals:- Bone density results within last 2 years: T-score less than -2.5 or T-score between -1 and -2.5 with documented risk factors
- Tried/failed or contraindication to oral therapy
- Normal calcium within 1 month of referral
- Serum creatinine within 1 month of referral (must demonstrate calculated creatinine clearance greater than 30 mL/min)
- Calculated creatinine clearance MUST be greater than 30 mL/min using the Cockcroft-gault equation
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Briumvi
Download Briumvi order form here.
Required clinicals:
- Negative Hep B
- Quantitative serum immunoglobulins
- MRI results within 1 year supporting MS diagnosis
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Cimzia
Download Cimzia order form here.
Required clinicals:- Negative TB (within 1 year)
- Negative Hep B
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Cinqair
Download Cinqair order form here.
Required clinicals:- Eosinophil count greater than 400 cells/microliter
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Cosentyx IV
Download Cosentyx IV form here
Required Clinicals:
- Prior to COSENTYX initiation, complete all age-appropriate vaccinations
- Negative TB test
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Crysvita
Download Crysvita order form here.
Required clinicals:
- Results of genetic testing to confirm dx
- Fibroblast growth factor 23 abover upper limit of normal
- Radiographic evidence of rickets or other bone disorder consistent with XLH
- Hypophosphatemia documented at start of therapy
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Dupixent
Download Dupixent order form here.
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Entyvio
Download Entyvio order form here.
Required clinicals:- Labs to include Hgb/Hct, CRP and/or ESR
- Colonoscopy results
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Evenity
Download Evenity order form here.
Required clinicals:- Bone density results within last 2 years: T-score less than -2.5 or T-score between -1 and -2.5 with documented risk factors
- Tried/failed or contraindication to oral therapy
- Normal calcium within 1 month of referral
- Serum creatinine within 1 month of referral (must demonstrate calculated creatinine clearance greater than 30 mL/min)
- Calculated creatinine clearance MUST be greater than 30 mL/min using the Cockcroft-gault equation
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Fabrazyme
Download Fabrazyme order form here.
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Fasenra
Download Fasenra order form here.
Required clinicals:- Baseline eosinophil at least 150 cells/microliter
- FEV1 less than 80% predicted value
- Incident of exacerbations in the last year
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Feraheme
Download Feraheme order form here.
Required clinicals:
- Low Hgb/Hct
- Iron studies including ferritin and transferrin
- Documented try/fail or contraindication to oral iron
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Hydration
Download Hydration order form here.
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Ilumya
Download Ilumya order form here.
Required clinicals:- Negative TB (within 1 year)
- Psoriasis involves at least 3% of body surface area
- Try/fail or contraindication to methotrexate
- Documentation that pt can't self-inject
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Inflectra
Download Inflectra order form here.
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Infliximab
Download Infliximab order form here.
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Injectafer
Download Injectafer order form here.
Required clinicals:- Low Hgb/Hct
- Iron studies including ferritin and transferrin
- Documented try/fail or contraindication to oral iron
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IVIG
Download IVIG order form here.
Required clinicals:
- Serum immunoglobulins
- Documentation to support specific disease
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Keytruda
Download Krystexxa order form here.
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Krystexxa
Download Krystexxa order form here.
Required clinicals:- Elevated serum uric acid prior to start of therapy
- Glucose 6 phosphate dehydrogenase (G6PD) antibody positive (within normal range)
- Documentation that patient has tried/failed or has a contraindication to conventional therapy
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Lemtrada
Download Lemtrada order form here.
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Lupron
Download Lupron order form here.
Required clinicals:- Clinical documents to support diagnosis
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Leqembi
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Leqvio
Download Leqvio order form here.
Required clinicals:- Elevated LDL-C (at least 190 mg/dL)
- Documentation that patient has tried/failed or has contraindication to high-dose statin therapy
- Documentation that patient has tried/failed or has contraindication to other conventional therapies
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Monoferric
Download Monoferric order form here.
Required clinicals:
- Low Hgb/Hct
- Ferritin and transferrin
- Documented try/fail or contraindication to oral iron
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Nucala
Download Nucala order form here.
Required clinicals:
- Clinical documentation supporting diagnosis of one of the following:
-Severe asthma
-Chronic rhinosinusitis w/ nasal polyps
-Eosinophilic granulomatosis w/ polyangiitis
-Hypereosinophilic syndrome - Tried and failed previous therapies
- For Asthma indications only: Documented eosinophil count, pre-treatment ≥150 cells/mcL
- Clinical documentation supporting diagnosis of one of the following:
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Nulojix
Download Nulojix order form here.
Required clinicals:
- Date of kidney transplant
- Documentation that patient is Epstein-Barr virus (EBV) seropositive
- Documentation that Nulojix is prescribed in combination with used in combination with basiliximab
induction, mycophenolate mofetil, and corticosteroids
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Ocrevus
Download Ocrevus order form here.
Required clinicals:- Negative Hep B
- Quantitative serum immunoglobulins
- MRI results within 1 year supporting MS diagnosis
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Omvoh
Download Omvoh form here.
Required clinicals:
- Negative TB test
- Baseline liver enzymes
- Bilirubin levels
- All age appropriate vaccinations
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Onpattro
Download Onpattro order form here.
Required clinicals:- Clinical documentation to support diagnosis
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Orencia
Download Orencia order form here.
Required clinicals:
- Negative TB (within 1 year)
- Negative Hep B screening (within 1 year)
- Labs to support diagnosis: Rheumatoid factor, anti-CCP, CRP, ESR
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Prolia
Download Prolia order form here.
Required clinicals:
- Bone density results within last 2 years: T-score less than -2.5 or T-score between -1 and -2.5 with documented risk factors
- Tried/failed or contraindication to oral therapy
- Normal calcium within 1 month of referral
- Serum creatinine within 1 month of referral (must demonstrate calculated creatinine clearance greater than 30 mL/min)
- Calculated creatinine clearance MUST be greater than 30 mL/min using the Cockcroft-gault equation
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QutenzaDownload Qutenza order form here.
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Reclast
Download Reclast order form here.
Required clinicals:
- Bone density results within last 2 years: T-score less than -2.5 or T-score between -1 and -2.5 with documented risk factors
- Tried/failed or contraindication to oral therapy
- Normal calcium within 1 month of referral
- Serum creatinine within 1 month of referral (must demonstrate calculated creatinine clearance greater than 30 mL/min)
- Calculated creatinine clearance MUST be greater than 30 mL/min using the Cockcroft-gault equation
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Remicade & Biosimilars
Download Remicade & Biosimilars order form here.
Required clinicals:
- Negative TB (within 1 year)
- Negative Hep B (within 1 year)
- For RA- Rheumatoid factor, anti-CCP, CRP, ESR
- For IBD- Colonoscopy
- Documentation that patient currently taking methotrexate OR
- Documentation that patient tried/failed or has contraindication to methotrexate
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Renflexis
Download Renflexis order form here.
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Rituxan & Biosimilars
Download Rituxan & Biosimilars order form here.
Required clinicals:
- Negative Hep B (within 1 year)
- Labs to support diagnosis (Rheumatoid Factor, anti-CCP, ANCA, ESR, CRP)
- Documentation that patient currently taking methotrexate OR
- Documentation that patient tried/failed or has contraindication to methotrexate
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Rituximab
Download Rituximab order form here.
Required clinicals:- Labs to include Hgb/Hct, CRP and/or ESR
- Colonoscopy results
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Rystiggo
Download Rystiggo order form here.
Clinical documentation supporting MG diagnosis
- Lab work confirming either:
- Anti-acetylcholine receptor (+)
- Anti-muscle specific tyrosine kinase (MuSK) antibody (+)
- Lab work confirming either:
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Saphnelo
Download Saphnelo order form here.
Required clinicals:
- Positive autoantibodies to support diagnosis (anti-ds DNA, ANA, anti-SM,
- Documentation that pt currently receiving one standard therapy
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Simponi Aria
Download Simponi Aria order form here.
Required clinicals:
- Negative TB (within 1 year)
- Negative Hep B (within 1 year)
- For RA- Rheumatoid factor, anti-CCP, CRP, ESR
- Documentation that patient currently taking methotrexate OR
- Documentation that patient tried/failed or has contraindication to methotrexate
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Skyrizi
Download Skyrizi order form here.
Required clinicals:
- Negative TB screening
- Failure of at least one conventional therapy OR
- Documentation of contraindication to conventional therapy
- Baseline liver enzyme and bilirubin
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Soliris
Download Soliris order form here.
Required clinicals:
- For PNH: Flow cytometry
- For gMG: anti-acetylcholine receptor antibodies
- Documentation of meningitis vaccine
- MGFA Clinical Classification
- MG-ADL total score
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Solumedrol
Download Solumedrol order form here.
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Spevigo
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Stelara
Download Stelara order forms here.
Rheumatology
GastroenterologyRequired clinicals:
- Negative TB
- Concurrent treatment with MTX or
- T/F or contraindication to MTX
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Tepezza
Download Tepezza order form here.
Required clinicals:
- T3/T4
- Documented Clinical Activity Score (CAS) at least 4
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Tezspire
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Truxima
Download Truxima order form here.
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Tysabri
Download Tysabri order form here.
Required clinicals:
- MRI results consistent with MS
- JCV antibody within 6 months
- For Crohn's: Colonoscopy
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Ultomiris
Download Ultomiris order form here.
Required clinicals:
- Ultomiris REMS enrollment
- Proof of meningococcal vaccination at least 2 weeks prior to start of treatment (If urgent Ultomiris therapy is indicated in an unvaccinated patient, administer meningococcal vaccine(s) as soon as possible and provide patients with two weeks of antibacterial drug prophylaxis
- Serum anti-acetylcholine receptor (AChR) antibody-positive
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Uplizna
Download Uplizna order form here.
Required clinicals:
- Anti-aquaporin 4 immunoglobulin/NMO-IgG antibodies
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Venofer
Download Venofer order form here.
Required clinicals:
- Low Hgb/Hct
- Iron studies including ferritin and transferrin
- Documented try/fail or contraindication to oral iron
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Vyepti
Download Vyepti order form here.
Required clinicals:
- Documentation to support diagnosis (to include evidence of at least 15 headache days/month and/or 8 migraine days/month)
- List of try/fail therapies
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Vyvgart
Download Vyvgart order form here.
Required clinicals:
- Positive serologic test for Anti-acetylcholine receptor antibody
- MuSK antibodies
- EMG results
- Myasthenia Gravis of America Clinical Classification score
- Myasthenia Gravis -specific Activities of Daily Living scale
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Vyvgart Hytrulo (SUB Q form of Vyvgart)
Download Vyvgart Hytrulo form here.
Required clinicals:
- Positive serologic test for Anti-acetylcholine receptor antibody
- MuSK antibodies
- EMG results
- Myasthenia Gravis of America Clinical Classification score
- Myasthenia Gravis -specific Activities of Daily Living scale
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Xgeva
Download Xgeva order form here.
Required clinicals:
- Serum calcium level (cannot be low) within 1 month of treatment
- Tried/failed or contraindication to oral therapy
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Xolair
Download Xolair order form here.
Required clinicals:
- Have a positive skin test or in vitro reactivity to a perennial aeroallergen.
- Baseline plasma immunoglobulin E (IgE) level w/in the following ranges as determined by age and weight in kg (see PI for full chart):
-Adult (12+yrs) 30 IU/ml - 700 Iu/ml
-Pediatric (6-12yrs) 30 IU/ml - 1300 IU/ml - FEV1 less than 80% predicted
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Zinplava
We continue to expand our offering. Please contact us if you receive routine infusions with another therapy that you don’t see on this list.
Hate faxing? You can also submit a digital order form and eSign. We'll send you a copy for your records.