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Section 1: Prescription Information
Share enough information for us to verify coverage or you can share the prescription. Our insurance verification team will navigate the payer coverage and requirements
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Therapy Type:{{Therapy Type 1}}
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Therapy administration history:
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Is Patient Currently On Therapy?
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Would you like to add another therapy type?
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Therapy Type:{{Therapy Type 2 }}
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Therapy administration history:
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Is Patient Currently On Therapy?
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Would you like to add another therapy type?
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Therapy Type:{{Therapy Type 3}}
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Therapy administration history:
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Is Patient Currently On Therapy?
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Pre-meds for IVIG:
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Pre-medications to be administered 30 minutes before start of IG (select all that apply):
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Would You Like to Upload a Written RX?
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Section 2: Required Patient Information
Minimal information to verify benefits includes the items in this section
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Is there a caregiver we should communicate with on behalf of the patient?
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Section 3: Insurance and Basic Clinical Information
Complete as much as possible about the patients demographics. Complete this section if you did not upload a demograhic file that included the items below.
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Does the patient have insurance coverage?
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How would you prefer to provide the insurance information we need to get started?
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Select the items you will upload related to the patient's insurance information:
*Please include demographic sheet along with Universal Claim Form for insurance records or reimbursement. (Attach Copies of cards)
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Section 4: Ordering Physician Information
If we have worked with the office in the past, you can skip the demographic information, but do confirm which physician is ordering.
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Section 5: Medical Information
Clinical Diagnosis: please upload, fax or email relevant clinical notes, labs, tests and previous medical history to expedite prior authorization. If you do not have this information at this time, please submit the referral anytime.
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Would you like to upload relevant clinical notes, labs, tests and previous medical history to expedite prior authorization?
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Drug Allergies:
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Weight Unit of Measurement:
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Height Unit of Measurement:
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For Apex Use Only:
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