Fillable Subcutaneous Immunoglobulin Enrollment Form printable pdf download

Faxed prescriptions will only be accepted from a prescribing practitioner. Patients must bring an original prescription to the pharmacy, and cannot fax these referral forms to Senderra.

Prescribing Practitioner:

Subcutaneous

Immunoglobulin

NPI:

Enrollment

Address:

Office:

Fax:

Main: 888-777-5547

Contact:

1301 E. Arapaho Rd., Ste. 101

Fax: 888-777-5645

Richardson, TX 75081

E-mail:

PATIENT INFORMATION

Name:

DOB:

SS#:

_____/_____/__________

______-______-___________

Tel:

Al. Tel:

Wt.:

Ht.:

English

Spanish

Other: ________

________

Street:

City:

State:

ZIP:

MEDICAL INFORMATION

ICD-10/Diagnosis Code:

Date of Diagnosis: ______________________________________________

Has patient received immune globulin previously?

Yes

IgA deficiency:

Yes

No IgA level _________ mg/dL Date:__________

If yes, product information: _______________________________________

IgG trough:______mg/dL Date:______ Diabetic:

Yes

Date of last infusion: ____________ Date of next infusion: _____________

Comorbidities:

Concomitant Medications:

Allergies:

PRESCRIPTION

New

Refill

Ship by: ____/____/____

SHIP TO:

Patient’s Home

Doctor’s Office

Other: ___________________

Hizentra® 20%

Weekly Sub-Q dose = IVIG Dose (g) x 1.37 / IVIG weekly interval originally given

HyQvia® 10%

Immune Globulin

Products

Complete the MyIg source form at orders and patient registration.

GammaKed™ 10%

Gammagard liquid® 10%

Gamunex-C® 10%

Weekly Sub-Q dose = IVIG Dose (g) x 1.53 / IVIG weekly interval originally given

Dose: ____________________ grams ___________________ times weekly

Therapy Regimen

# Doses: __________________ Refill: ____________________

Administration rate and number of sites:

Per manufacture guidelines, as tolerated

_________________________

Acetaminophen Take __________ mg by mouth every 4-6 hours as needed for fever and/or headache

Diphenhydramine Take __________ mg by mouth every 4-6 hours as needed for itching

Other Medications

Drug: _________________________________ Strength: _____________________ Qty: ______________________

Directions: _____________________________________________________________________ Refills: __________

Orders:

Stop infusion

Call 911 and prescribing physician

Administer medications below as per protocol

Epinephrine

Anaphylaxis Orders

EpiPEN® - Administer 0.3 mg (1:1000) subcutaneously as needed (≥ 30 Kg or ≥ 66 lbs)

and Medications

EpiPEN Jr® - Administer 0.15 mg (1:2000) subcutaneously as needed (< 30 Kg or < 66 lbs)

Qty: _________ Refill: _________

Ancillary Supplies

As needed for proper administration and disposal of medication

To train patient/caregiver in Subcutaneous Immune Globulin administration, provide education related to disease state/therapy and

Skilled Nursing Visits

assess general status. Typically, 3 training visits required. Once trained and able to return demonstrate, patient/caregiver to self-

administer Subcutaneous Immune Globulin medication independently

All nursing services requirements to be completed per pharmacy protocol.

***PLEASE FAX COPY OF PRESCRIPTION/MEDICAL CARD, FRONT AND BACK, AS WELL AS ANY CLINICAL NOTES REGARDING THERAPY***

INJECTION TRAINING

□

Patient has received pen and injection training

Physician’s office to provide injection training

Senderra Rx to coordinate injection training

PRESCRIBING PRACTITIONER SIGNATURE

To Prescribing Practitioner: By signing this form and utilizing our services, you are also authorizing Senderra Rx to serve as your prior authorization designated agent in dealing with medical and

prescription insurance companies, and co-pay assistance foundations.

Date:

Prescribing

Practitioner:

_______/________/____________

CONFIDENTIALITY NOTICE

IMPORTANT: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, proprietary or exempt from disclosure under applicable law. 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 in error and then destroy this document immediately.

Subcutaneous Immunoglobulin Enrollment (Rev. 04/18/2016)

Subcutaneous Immunoglobulin Enrollment Form

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