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
- Absolute neutrophil count, platelets, liver function tests, lipid panel
- For RA- Rheumatoid factor, anti-CCP, CRP, ESR
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Alpha 1-Proteinase Inhibitor (Human)
Download Alpha 1-Proteinase Inhibitor (Human) order form here.
Available options:- Prolastin-C
- Glassia
- Zemaira
- Aralast
Required clinicals:
- Baseline percent predicted FEV1
- Baseline serum AAT level or documentation of Alpha- antitrypsin deficiency emphysema
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Amvuttra
Download Amvuttra order form here.
Required clinicals:
- Supporting clinical notes to support primary diagnosis
- Baseline polyneuropathy disability (PND) score
- Documentation of a gene TTR mutation
- Supporting clinical notes to support primary diagnosis
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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
- Negative Hep B
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Cinqair
Download Cinqair order form here.
Required clinicals:- Eosinophil count greater than 400 cells/microliter within 1 month of referral
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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 above upper limit of normal
- Radiographic evidence of rickets or other bone disorder consistent with XLH
- Documentation of current oral phosphate or active vitamin D analogs
- Serum phosphorus within 1 month of referral
- Serum creatinine within 1 month of referral
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Entyvio
Download Entyvio order form here.
Required clinicals:- Colonoscopy results
- Negative TB
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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
- Documented calcium and Vit D supplementation
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Evkeeza
Download Evkeeza order form here.
Required clinicals:
- LDL lab level
- Documentation that patient is currently on another LDL-C lowering agent/med
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Fabrazyme
Download Fabrazyme order form here.
Required clinicals:
- Clinical documentation to support Fabry disease
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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:
- Complete Blood Count (CBC) and iron studies (ferritin and/or iron level) that demonstrate iron deficiency/anemia within 1 month of referral
- Documented try/fail or contraindication to oral iron
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Hydration
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HyQvia
Download Hyqvia order form here.
Required clinicals:
- Other labs: ANA, anti-dsDNA
- Documentation to support specific disease
- Serum immunoglobulins
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Ilumya
Download Ilumya order form here.
Required clinicals:- Negative TB
- 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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Injectafer
Download Injectafer order form here.
Required clinicals:- Complete Blood Count (CBC) and iron studies (ferritin and/or iron level) that demonstrate iron deficiency/anemia within 1 month of referral
- Documented try/fail or contraindication to oral iron
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IVIG
Download IVIG order form here.
Required clinicals:
- Serum immunoglobulins
- Other labs: ANA, anti-dsDNA
- Documentation to support specific disease
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Keytruda
Download Keytruda order form here.
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Kisunla
Download Kisunla order form here.
Required clinicals:
- Baseline MRI within 1 year, with repeat MRIs needed prior to the 5th, 7th and 14th infusion
- Cognitive assessment and score
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Krystexxa
Download Krystexxa order form here.
Required clinicals:- Supporting documentation for gout diagnosis; synovial fluid studies, radiographic imaging, letter of medical necessity
- G6PD results
- Serum uric acid level within 1 month for initiation of therapy, within 48 hours for ongoing treatments
- Documentation of initiation of Methotrexate and folic acid
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Lupron Depot
Download Lupron order form here.
Required clinicals:- Clinical documents to support diagnosis
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Leqembi
Download Leqembi order form here.
Required clinicals:
- APoE4 status
- Confirmation of amyloid beta pathology
- Baseline MRI within 1 year, with repeat MRIs needed prior to the 5th, 7th and 14th infusion
- Cognitive assessment and score
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Leqvio
Download Leqvio order form here.
Required clinicals:- LDL-C
- 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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Magnesium Sulfate
Download Magnesium Sulfate order form here.
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Monoferric
Download Monoferric order form here.
Required clinicals:
- Complete Blood Count (CBC) and iron studies (ferritin and/or iron level) that demonstrate iron deficiency/anemia within 1 month of referral
- 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
- Documentation of tried and failed therapies
- 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
- Negative TB results
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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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Ocrevus ZunovoDownload Ocrevus Zunovo 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
- TTR protein variants
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Orencia
Download Orencia order form here.
Required clinicals:
- Negative TB
- Negative Hep B
- Labs to support diagnosis: Rheumatoid factor, anti-CCP, CRP, ESR
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Pemgarda
Download Pemgarda order form here.
Download List of billable ICD-10 codes here.
Required clinicals:
- Documentation of a diagnosis categorizing the patient to be considered moderately to severely immunocompromised
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Phesgo
Download Phesgo order form here.
Required clinicals:
- Documentation of which combined therapy patient is currently on
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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
- 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
- Calcium and vitamin D supplementation (alternatively documentation that reveals patient has been educated on adequate dietary supplementation is sufficient)
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Qutenza
Download Qutenza order form here.
Required clinicals:
- Supporting documents for diagnosis
- Clinical diagram showing where provider would like patches and how many -form provided by pharma
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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
- 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
- Calcium and vitamin D supplementation (alternatively documentation that reveals patient has been educated on adequate dietary supplementation is sufficient)
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Remicade & Biosimilars
Download Remicade & Biosimilars order form here.
Required clinicals:
- Negative TB
- Negative Hep B results
- Recent Labs
- Most recent colonoscopy
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Rituxan & Biosimilars
Download Rituxan & Biosimilars order form here.
Required clinicals:
- Negative Hep B
- 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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Rystiggo
Download Rystiggo order form here.
Clinical documentation supporting MG diagnosis
- Clinical documentation supporting MG diagnosis
- Lab work confirming either: Anti-acetylcholine receptor (+) or Anti-muscle specific tyrosine kinase (MuSK) antibody (+)
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Saphnelo
Download Saphnelo order form here.
Required clinicals:
- Labs conclusive with SLE dx (ANA, anti-dsDNA, anti-SM, anti-Ro/SSA, anti-LA/SSB)
- Currently receiving at least on standard treatment (non-biologic) or contraindication (e.g. antimalarial, corticosteroid, immunosuppressants)
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Simponi Aria
Download Simponi Aria order form here.
Required clinicals:
- Negative TB
- Negative Hep B
- Positive for RF or anti-CCP OR Tested for all biomarkers but results negative (RF, 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
- Normal liver enzymes (ALT/AST) and bilirubin (For Crohn’s and Ulcerative Colitis patients) prior to initiation of therapy
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Soliris
Download Soliris order form here.
Required clinicals:
- Anti-AChR+ (for gMG)
- Anti-AQP4 Antibody positive (for NMOSD)
- Documentation of meningitis vaccine (at least 2 weeks before 1st infusion)
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Solumedrol
Download Solumedrol order form here.
Required clinicals:
- Supporting clinical documentation for diagnosis and rationale for steroid treatment
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Spevigo
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Stelara
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Tepezza
Download Tepezza order form here.
Required clinicals:
- Clinical Assessment Score (CAS)
- Labs that prove euthyroid or mild hypo/hyperthyroidism undergoing treatment to correct and/or maintain euthyroid
- Thyroid panel within 1 month of referral prior to initiation of therapy
- Hearing tests completed prior to treatment
- Pregnancy test
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Tezspire
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Tremfya
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Tysabri
Download Tysabri order form here.
Required clinicals:
- Most recent MRI results consistent with MS
- JCV antibody test within 6 months
- For Crohn's: Colonoscopy
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Tzield
Download Tzield order form here.
Required clinicals:
- Complete blood count and Liver Enzyme tests (LFTs) within 1 month of treatment
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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
- Negative Hep B
- Negative TB
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Venofer
Download Venofer order form here.
Required clinicals:
- Complete Blood Count (CBC) and iron studies (ferritin and/or iron level) that demonstrate iron deficiency/anemia within 1 month of initiation of therapy
- Documented try/fail or contraindication to oral iron
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Vitamin B 12 Injection
Download Vitamin B 12 Injection order form here.
Required clinicals:
- Documentation/labs supporting diagnosis
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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:
- DEXA results (T-score less than or equal to -2.5) OR T-score between -1 and -2.5 with FRAX scores that show high risk of fracture
- Calcium and vitamin D supplementation (alternatively documentation that reveals patient has been educated on adequate dietary supplementation is sufficient)
- Serum calcium level within 1 month of referral
- Serum creatinine level within 1 month of referral
- 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
Download Zinplava order form here.
Required clinicals:
- Positive stool sample for C diff
- Documentation that patient is currently on antibiotic therapy
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.