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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
"INTRAVENOUS IMMUNE GLOBULIN ENROLLMENT FORM"