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
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