Fax completed form to Fax to the number provided by our intake team
Questions:
1574 Henthorne Drive, Suite C, Maumee, OH 43537
Questions:
1574 Henthorne Drive, Suite C, Maumee, OH 43537
Infusion and injection order form
Patient
Patient name
Date of birth
Sex
Address
Phone
Height
Weight
Allergies
Insurance (attach front and back of all cards)
Primary plan
Member ID
Group number
Secondary plan
Member ID
Group number
Diagnosis
Diagnosis
ICD-10 code(s)
Order
Medication
Dose
Frequency
Duration or number of doses
Loading or induction schedule, if any
- IV infusion
- IV push
- Subcutaneous
- Intramuscular
- First dose of this medication
- Continuing therapy
Pre-medications and labs
Pre-medications (drug, dose, route)
Labs to draw at visit and how often
Clinical information
TB screening date and result
Hepatitis B screening date and result
Therapies tried and failed
Special instructions
Prescriber
Prescriber name
NPI
Practice
Office phone
Office fax
Office contact
Prescriber signature
Date
Please attach
- Demographics and insurance cards
- Recent office notes
- Recent labs
- Current medication list
- Prior authorization, if already obtained
Screening results are needed only where the prescribed therapy calls for them. This fax contains confidential health information intended for Maumee Integrated Health. If you received it in error, please notify Maumee Integrated Health and destroy all copies.