Oncology Infusion Referral Form

Date Shipment Needed:
_ Ship To:  Patient  Physician  Nursing needed  Training needed
►All the supplies including syringes and needles will be dispensed if needed for medications that are administered at patient’s home.
Phone: 866-892-1580 Fax: 866-892-2363
Oncology Infusion Referral Form
Patient Name:
Physician Name:
Address:
City:
State:
Phone#1: (
)
Phone#2: (
-
Zip:
)
Patient Soc. Sec #:
/
Height:
BSA:
Primary Insurance:
City:
Plan #:
Group #:
Phone: (
)
-
Sex: Male Female Weight
/
m²
__________
-
City:
State:
Physician’s Ph: (
lbs kg
)
Physician’s Fax: (
Zip:
-
)
_
-
See attached demographic sheet
Nurse/Key Office Contact:
INSURANCE INFORMATION (Complete or Attach Copies of cards)
Secondary Insurance:
City:
State:
Plan #:
Group #:
Phone: (
)
-
State:
Specialty:
Address:
)
Allergies:
Date of Birth:
DEA #
NPI #
Practice Name/Hospital:
-
Emergency Contact Name (Required):
Emergency Contact Phone # (Required): (
State Lic #
Rx Card (PBM):
PBM BIN:
City:
Group #:
Phone: (
)
Cardholder First Name:
Last Name:
Employer:
ID #:
Group #:
State:
-
_
MEDICAL ASSESSMENT
Diagnosis: Breast Cancer Renal Cell Carcinoma
Colon Cancer
Colorectal Cancer Non-small cell lung cancer Glioblastoma 
Chronic Lymphocytic Leukemia
Non-Hodgkin’s Lymphoma BCG refractory carcinoma in situ (CIS) of the urinary bladder when immediate cystectomy would be associated with morbidity and mortality
 Malignant melanoma, Unresectable or Metastatic

Metastatic gastric or gastroesophageal junction adenocarcinoma
Other
 Cancer Stage: Stage 0 Stage I Stage II
Stage III
Stage IV Other
 Has patient been treated previously for this condition? Yes No (If pt has been on Xeloda, please indicate dose and duration of therapy) Medications:
 Is patient currently on therapy? Yes No Medications:
 Will patient stop taking the above medication(s) before starting the new medication?
Yes No If yes, what is the washout period?
 Other medications patient is currently taking including OTC medications with dosage and direction (or fax medication profile):

ARZERRA

AVASTIN

GAZYVA

HERCEPTIN

IXEMPRA

KADCYLA

KEYTRUDA

OPDIVO

mg QTY:
Sig:
Refill:
_mg QTY:
Sig:
Refill:
_mg QTY:
Sig:
Refill:
Sig:
Refill:
Sig:
Refill:
mg QTY:
Sig:
Refill:
_mg QTY:
Sig:
Refill:
_mg QTY:
Sig:
Refill:
PERJETA
_mg QTY:
Sig:
Refill:

RITUXAN
_mg QTY:
Sig:
Refill:

YERVOY
mg QTY:
Sig:
Refill:

OTHER
mg QTY:
Sig:
Refill:
_mg QTY:
_mg QTY:
Physician’s Signature:














ALIMTA
Sig:
ABRAXANE
Sig:
ADCETRIS
Sig:
CARBOPLATIN Sig:
CISPLATIN
Sig:
DOCETAXEL Sig:
ERBITUX
Sig:
GEMCITABINE Sig:
JEVTANA
Sig:
OXALIPLATI Sig:
PACLITAXEL Sig:
TORISEL
Sig:
VELCADE
Sig:
ZOMETA
Sig:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Qty:
Infusion Cycle Refills:
Infusion Cycle
Refills:
Infusion Cycle
Refills:
Infusion Cycle
Refills:
Infusion Cycle
Refills:
Infusion Cycle
Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
Infusion Cycle Refills:
ANTIEMETICS:
 Chemo-induced N/V
 ALOXI
Strength:
_Sig:
 EMEND
Strength:
_Sig:
 DOLASETRON
Strength:
_Sig:
 GRANISETRON
Strength:
_Sig:
 ONDANSETRON
Strength:
_Sig:
 PROCHLORPERAZINE Strength:
_Sig:
SUPPORTIVE AGENTS:
 ARANESP
Strength:
 EPOGEN
Strength:
 NEULASTA
Strength:
 NEUMEGA
Strength:
 NEUPOGEN Strength:
 PROCRIT
Strength:
 PROTHELIAL Strength:

Sig:
Sig:
Sig:
Sig:
Sig:
Sig:
Sig:

DAW (Dispense as Written)
_
Radiation-induced N/V
Qty:
Refills:
Qty:
Refills:
Qty:
Refills:
Qty:
Refills:
Qty:
Refills:
Qty:
Refills:
Qty:____Refills:
Qty:____Refills:
Qty:____Refills:
Qty:____Refills:
Qty:____Refills:
Qty:___Refills:
Qty:____Refills:
Date
/
/
Prescriber certifies that this referral form contains an original signature and is signed by the treating physician IMPORTANT NOTICE: This message may contain privileged and confidential information and is intended only for
the individual named. If you are not the named addressee, you should not disseminate, distribute or copy this fax. Please notify the sender immediately if you have received this document by mistake, then destroy this document.
Please direct all verification or notification to AcariaHealth or any of its subsidiaries using the contact information provided on this coversheet.
Rev. 10.01.2015