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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O ADDITIVES LIST CODE SUBSTANCE Animal genes damage, possible risk to conception and cancer. Still being evaluated regarding reproductive toxicity. Linked to hyperactivity, skin rashes, migraines, behavioural problems, thyroid problems, chromosome damage. Banned in Norway and Austria. Linked to hyperactivity, skin rashes, asthmatics should avoid. Banned in USA and Norway - previously banne
Simponi ARIA® (golimumab) Referral Form