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INTRAVENOUS IMMUNE GLOBULIN
ENROLLMENT FORM
(Please Print)
PAT IENT INFORM ATION
Patient’s last name: First: Middle Init. Marital status: Single / Mar
Mr. Miss
Mrs. Ms.
Div / Sep / Wid
Street address: Birth date: Sex:
/ / M F
City: State: ZIP Code: County:
Day phone no.: Night phone no.: Allergies
( ) ( )
INSURANCE INF ORMAT IO N
Name of primary insurance: Primary cardholder’s name: Group no.: Member id:
Employer: Patient’s relationship to cardholder:
Child Spouse Self Other
Name of secondary insurance: Secondary cardholder’s name: Group no.: Member id:
Employer: Patient’s relationship to cardholder:
Child Spouse Self Other:
PHYSICIAN INF ORMAT ION
Prescriber’s last name: First: Middle init. Hospital/Clinic: Office Contact Name:
Street address: DEA no.: UPIN:
City: State: ZIP Code: Medicaid provider no.:
County: Phone no.: Fax phone no.:
( ) ( )
MEDICAL INFORM ATION
Primary Diagnosis Any infection in the last 30 days? Yes No
Primary immune definciency (Hypogammaglobulinemia, unspecified) (ICD 279.0) If yes, what type? (Check all that apply below)
Idiopathic thrombocytopenia purpura (ICD 287.5) Pneumonia with fever (ICD 461.1 – 473.8)
Bone marrow transplant (ICD V42.81, 2) Sinusitis (ICD 461 – 473.8)
Kawasaki syndrome (ICD 466.1) Otitis media (ICD 381.0 – 382.9)
Human immunodeficiency virus (HIV) (ICD 042) Others, specify: (ICD: )
Patient weight kg/lb Date taken: / / Any hospitalizations in the last 30 days? Yes No
If yes, number of hospitalizations: and length of stay:
Patient is IgA deficient? Yes No New Start Yes No Date of last infusion: / /
If yes, what is the Iga level? mg/dL Date taken: / /
Prescription
(Check only one box)
Recent IgG trough: mg/dL Date taken: / / Pharmacy authorized to fill currently available IVIG product
Gammagard 10% S/D Powder (only available upon manufacturer determination of true IgA deficiency)
Patient is diabetic: Yes No Other, specify:
If yes, what is the current HbA1c? % Date taken: / /
Total grams to be infused: Infusion interval:
Doses need for 30 day supply: Next infusion date: / /
Recent IgG trough: mg/dL Date taken: / / Refill: 1 year Other:
Infusion supplies required
Renal function: Serum creatinine: mg/dL Date taken: / / Standard kit for peripheral intravenous access
Standard kit for Infusaports
Ship medication to:
Liver function: AST: U/L ALT: U/L Date taken: / / Patient Home Physician Office Other
Pharmacy to coordinate home infusion by a skilled nurse Yes No
Prescriber’s signature Date
10905 Fort Washington Road ▪ Suite #403 ▪ Fort Washington, Maryland 20744 ▪
Phone: 301-203-3382 ▪ Fax: 301-203-3385
