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INTRAVENOUS IMMUNE GLOBULIN ENROLLMENT FORM by mifei

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									                                                                   INTRAVENOUS IMMUNE GLOBULIN
                                                                         ENROLLMENT FORM
                                                                                                          (Please Print)
                                                                                                   PATIENT INFORMATION
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 INFORMATION
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 INFORMATION
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 INFORMATION
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

								
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