Scig Referral Form - Primary Immune Deficiency, Statement Of Medical Necessity

SCIG Referral Form – Primary Immune Deficiency

Statement of Medical Necessity    

 

             

 

 

 

 

 

 

 

Fax   C ompleted   F orm   t o   8 55-­‐ 7 08-­‐5840  

Initial   O rders  

 

It   i s   r ecommended   t o   s tart   a ll   s ubcutaneous   t herapies

1   w eek   a fter   l ast  

For   q uestions   c all   -­‐   8 00-­‐223-­‐4376  

 

IVIG   i nfusion.  

 

  L ast   d ose   o f   I VIG:   _ _______   g rams        

PATIENT   I

NFORMATION  

Has   t he   p atient   b een   o n   p revious   s ubcutaneous   p roduct:   0 NO       0   Y ES  

Patient   N ame:  

 

 

Brand:   _ ____________________________             D ose:   _ ______   g rams  

Address:  

 

 

City:    

State:    

Zip:    

Brand:     0   H izentra       0 HyQvia     0 Gammagard   0 Gamunex     0 Gammaked        

 

  □

DOB:  

 

Gender:  

□

  M ale              

  F emale  

 

Height:  

 

Weight:    

0   P harmacy   t o   d etermine   i nfusion   r ate   a nd   d osing  

 

Phone   ( Home):  

 

Phone   ( Cell):    

 

□

  A llergies:  

0   H izentra   D ose:  

 

Infuse   _ _______grams   o f   H izentra   s ubcutaneously,   n ot   t o  

□  

N KDA  

exceed   m ore   t han   4   s ites.   R epeat   e very   _ _______   w eek(s).  

Patient   R ecords   ( Please   A ttach   a nd   F ax):  

Pump:   S   F reedom   6 0   s yringe   p ump.  

1.

Insurance   C ard(s)    

2.

Demographic   I nformation  

0Other:  

3.

Recent   C linical   A ssessment   o r   H istory   &   P hysical  

0   H yQvia   D OSE:  

4.

Current   M edication   L ist  

Total   H yQvia   d ose:     _ ______       g rams.    

STATEMENT   O F   M EDICAL   N ECESSITY   –   P RIMARY   D

IAGNOSIS  

Follow   i nitial   t herapeutic   d ose   r amping   s chedule:  

□   C ommon   V ariable   I mmunodeficiency   ( CVID)  

279.06  

     

First   i nfusion/week   1 :   2 5%   o f   d ose

□   C ombined   I mmunity   D eficiency   &   S CID  

279.2  

:  

 

Second   i nfusion/   w eek   2

5 0%   o f   d ose.

 

□   C ongenital   H ypogammaglobulinemia  

279.04  

                                                                                                   

Third   i nfusion/   w eek   4 :   7 5%   o f   d ose:

□   H ypogammaglobulinemia  

279.00  

 

Fourth   i nfusion/   w eek   7 :   F ull   d ose

□   I mmunodeficiency   w ith   I ncreased   I gM  

279.05  

 

*Nursing   v isits   r equired   u ntil   p atient   i s   i ndependent   w ith   t herapy

□   I mmunodeficiency   w ith   P redominant   T -­‐Cell   D efect,          

279.10  

        U nspecified  

 

Infusion   R ate   f or   H yQvia   ( Per   m anufacturer   g uidelines):  

□   S elective   I gA   I mmunodeficiency  

279.01  

T   R ate   i ntended   f or   p atients   g reater   t han   8 8   p ounds.  

□   S elective   I gM   I mmunodeficiency  

279.02  

E lectronic   i nfusion   p ump   r equired   t o   d eliver   t herapy.  

S  

□   W iskott   –   A ldrich   S yndrome  

279.12  

Recombinant   H uman   H yaluronidase   S C   p ush   a t   1 -­‐ 2 mL/min/site                    

□   O ther   S elective   I mmunodeficiency  

279.03  

Adult   H YQVIA   1 0%   :  

□   O ther__________________________________  

   

First   2   I nfusions                                                                                         S ubsequent   i nfusions:  

10ml/hr   f irst   1 5   m inutes                                                           1 0ml/hr   f irst   1 5   m inutes  

PHYSICIAN   I

NFORMATION  

30ml/hr   n ext   1 5   m inutes                                                         3 0ml/hr   n ext   1 5   m inutes  

Physician   N ame:    

60ml/hr   n ext   1 5   m inutes                                                         1 20ml/hr   n ext   1 5   m inutes  

Office   C ontact:  

 

120ml/hr   n ext   1 5   m inutes                                                     2 40ml/hr   n ext   1 5   m inutes  

(required)  

240ml/hr   r emainder   o f   i nfusion                                 3 00ml/hr   r emainder   o f   i nfusion  

0Other:    

Phone:  

 

Fax:    

Address:  

 

 

Anaphylaxis   k it   w ill   b e   p rovided   c ontaining:  

City:  

 

State:    

Zip:    

Epinephrine   ( Adrenaline)   1 :1000   1 ml   A mp   # 1  

License:    

Diphenhydramine   ( Benadryl)   5 0   m g   1 ml   1   m L   A mp   # 1  

DEA:  

 

Syringe   3 ml   w /needle   # 1  

NPI:    

Tuberculin   s yringe   1 ml   ½ ”   n eedle   # 2  

Alcohol   P ads   # 3  

I   c ertify   t hat   t he   u se   o f   t he   i ndicated   t reatment     i s   m edically    

*

Epi-­‐ p en   s cript   m ust   b e   s ent   t o   p atient’s   p harmacy,   b efore   t he   p atient  

necessary,   a nd   I   w ill   b e   s upervising   t he   p atient’s   t reatment.   M y  

is   c onsidered   “ Independent”   w ith   t herapy.  

signature   a uthorizes   n ursing   a nd   p harmacy   s ervices   i n   a ccordance  

with   e stablished   p olicy   a nd   p rocedures.   P lan   o f   T reatment   w ill   b e  

Premedication   ( To   b e   t aken   1 5-­‐30   m inutes   p rior   t o   s tart   o f   t herapy):  

submitted   a fter   t he   i nitial   n ursing   a ssessment.   I   a cknowledge   t hat  

0Tylenol   _ ____mg     P O                   0   Z ofran   _ ______mg   P O/IV  

I   w ill   b e   p eriodically   b e   r eviewing   a nd   s igning   t he   w ritten   P lan   o f  

0Benadryl   _ ______mg     P O/IV     0   O ther:   _ ____________mg   P O/IV  

Treatment   i n   a ccordance   w ith   s tate   r egulations.  

0EMLA   C ream     0 Other:____________________________________  

 

Labs:   0   N one     0 Yes:   _ _____________________________________  

Physician   S ignature:  

 

 

0   P lease   a llow   r efills   a s   n eeded   f or   o ne   y ear.  

Date:  

 

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□  

□  

Activities:  

U p   a s   t olerated      

B edrest        

B edrest/Bathroon   o nly  

□  

□  

  □

W heelchair        

W alker        

Other   _ ________________________  

 

Diet:                     _ ______________________________________________