Refer a Patient for Infusion Services
Partnering in Patient Care
Thank you for trusting us to support your patient’s care. To refer a patient for specialty infusion services, please follow the steps below.
Step 1: Choose the Appropriate Order Form
Download and complete the therapy-specific order form for your patient’s infusion service.
If the therapy you are looking for is not listed, please use the General Therapy Provider Order Form.
Search by brand name below to find the appropriate order form. Generic and biosimilar names are included to help you identify the correct therapy.
Actemra®, Avtozma®, Tofidence®, Tyenne®
Generic: Tocilizumab, Tocilizumab-anoh, Tocilizumab-bavi, Tocilizumab-aazg
Amvuttra®
Generic: Vutrisiran
Avsola®, Inflectra®, Remicade®, Renflexis®
Generic: Infliximab
Benlysta®
Generic: Belimumab
Briumvi®
Generic: Ublituximab
Evenity®
Generic: Romosozumab-aqqg
Evkeeza®
Generic: Evinacumab-dgnb
Imaavy™
Generic: Nipocalimab-aahu
Kinsula®
Generic: Donanemab-azbt
Leqembi®
Generic: Lecanemab-irmb
Nulojix®
Generic: Belatacept
Ocrevus®
Generic: Ocrelizumab
Ocrevus Zunovo™
Generic: Ocrelizumab and Hyaluronidase
Omvoh®
Generic: Mirikizumab-mrkz
Orencia®
Generic: Abatacept
Prolia®, Bildyos®, Bosaya®, Conexxence®, Jubbonti®, Ospomyv™, Stoboclo®
Radicava®
Generic: Edaravone
Rituxan®, Riabni®, Ruxience®, Truxima®
Generic: Rituximab, Rituximab-arrx, Rituximab-pvvr, Rituximab-abbs
Saphnelo®
Generic: Anifrolumab
Soliris®, Bkemv®, Epysqli®
Generic: Eculizumab, Eculizumab-aeeb, Eculizumab-aagh
Tremfya®
Generic: Guselkumab
Tysabri®, Tyruko®
Generic: Natalizumab, Natalizumab-sztn
Tzield®
Generic: Teplizumab
Ultomiris®
Generic: Ravulizumab
Uplizna®
Generic: Inebilizumab
Vyepti®
Generic: Eptinezumab-jjrm
Vyvgart®
Generic: Efgartigimod Alfa
Vyvgart Hytrulo®
Generic: Efgartigimod Alfa and Hyaluronidase
If the therapy you are looking for is not listed, please use the General Therapy Provider Order Form.
- Alyglo® 10%
- Asceniv™ 10%
- Gammagard® Liquid
- Gammagard® S/D
- Gammaked™ 10%
- Gamunex®-C 10%
- Octagam® 5%, 10%
- Panzyga® 10%
- Privigen® 10%
- Qivigy® 10%
If the therapy you are looking for is not listed, please use the General Therapy Provider Order Form.
- Cutaquig® 16.5%
- Hizentra® 20%
- HyQvia® 10%
- Xembify® 20%
If the therapy you are looking for is not listed, please use the General Therapy Provider Order Form.
Step 2: Fax the completed form.
Once completed, fax the form to 954-276-1003.
For questions about the referral process, please call 1-844-276-6948.