ORBACTIV ORITAVANCIN) Referral order form Fax (877 637 6691 · 2019. 11. 17. · Fax (877) 637-6691...
Transcript of ORBACTIV ORITAVANCIN) Referral order form Fax (877 637 6691 · 2019. 11. 17. · Fax (877) 637-6691...
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Fax (877) 637-6691
Patient information Physician information
Date:Name:
DOB: SS#
Phone #
ORBACTIV medication orders
indication/diagnosis notes (additional inFo)
ABSSSIOther
required documentation
Insurance Cards (front and back)
Recent Office notes (along with any therapies tried and outcomes) Current Medication List History and Physical Report (w/in past 6 months)
Lab Results Demographic Sheet
ORBACTIV (ORITAVANCIN) Referral order form
12/2016
aPPointment date & time:fOR OffICE USE ONLY
New Referral Medication/ Order Change (New Order Required)
Email:
D/C Infusions *indicate name of drug(s)
Benefits Verification Only
*iCd-10 required
Referring Physician’s Signature Date
Restart
Patient Weight: kg
Referring Physician:
Office Contact:
Contact Phone #
NPI / DEA#:
Contact Fax #
Practice Address:
www.vascoinfusion.comPH: 602-346-0204 fax: 877-637-6691
Dose: 1200mg
Vasco Infusion can accept only original prescription drug orders from patients, and faxed prescriptions from the prescribing practitioners.
Refills: