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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://www.ntinfusioncenters.net/images/Simponi_Referral_Form.pdf

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COLORADO REPRODUCTIVE ENDOCRINOLOGY 4600 HALE PARKWAY, SUITE 350 PATIENT NAME: DENVER, CO 80220 303-321-7115 FAX 303-321-9519 ATIENT HISTORY FORM PHYSICIAN: Please answer the fol owing questions to the best of your ability. The information obtained wil enable us to provide you with optimal medical care. If you do not know the answer to any questions, you may leave it

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