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New Referral
Continuing Treatment
Medication Order Change
Patient Information
Physician Information
Name
Referring Physician
Date
Address
DOB
Phone
SS#
Fax
Phone
Email
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Medication Orders
Physician Address (if
Patient Weight (kg)
Patient Height (inches)
Dosing
4mg/kg IV for 1st infusion and then 8mg/kg every 4 weeks thereafter
8mg/kg IV every 4 weeks
6mg/kg IV every 4 weeks
4mg/kg IV every 4 weeks
Premeds (if applicable)
Indication / Diagnosis:
M05.79 Rheumatoid arthritis with rheumatoid factor without organ or systems involvement
M06.9 Rheumatoid arthritis, unspecified
M31.6 Giant Cell Arteritis
Other (please specify)
Signature
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NPI
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