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Simponi_referral_form

Simponi ARIA® (golimumab) Referral Form
Patient Information
____________________________________________________________________________________________________________________________________________________________________________________
Last Name
____________________________________________________________________________________________________________________________________________________________________________________ Street Address ____________________________________________________________________________________________________________________________________________________________________________________ Phone (daytime)
____________________________________________________________________________________________________________________________________________________________________________________
Primary Insurance Information
Secondary Insurance Information Pharmacy Insurance Card____
__________________________________________________________________________________________________________________________________________________________________________________ Insurance Name ____________________________________________________________________________________________________________________________________________________________________________________ Cardholder Name ____________________________________________________________________________________________________________________________________________________________________________________ Group / Policy Number
Physician Information
___________________________________________________________________________________________________________________________________________________________________________________
Physician Name
___________________________________________________________________________________________________________________________________________________________________________________ Street Address __________________________________________________________________________________________________________________________________________________________________________________ Physician’s DEA Number
Statement of Medical Necessity : PLEASE INCLUDE A COPY OF CHART DOCUMENTATION OF DIAGNOSIS CODES
Other Rheumatoid Arthritis with visceral or systematic involvement ICD-9 Code: 714.2
Date Diagnosed:________________________________________
Medical History :
Patient Weight: _____(Lbs) / _____(Kgs) Height:__________
Tuberculin (PPD) skin test date_____________ Negative Positive If positive: date of last X-Ray:_________________
Hep B Surface Antigen test date____________ Negative Positive
Allergies:___________________________________________________________________________________________________________________________________________________________________________________________________

Prescription Orders:


Simponi ARIA® (golimumab)

Sig: 2mg/kg intravenous (IV). Infuse over 30 minutes. Infuse day 0, 4 weeks then every 8 weeks.
Pre-medications: Acetaminophen 650 mg PO Benadryl 25mg IVP
Promethazine 25mg IVP Solu-Medrol 40 mg IVP Benadryl 25mg PO Other Premeds Needed __________________________________
Standing lab orders: CMP CBC ESR
CRP other:__________________________ every infusion
Refills: _______times or 12 months.

___________________________________________________________________________________________
Physician’s signature

Fax completed form to (214) 887-0436. Contact us directly at: (214) 276-5642.
Or visit us online at www.ntinfusioncenters.com

Source: http://ntinfusioncenters.info/images/Simponi_Referral_Form.pdf

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