GLASSIA INFUSION ORDER - 02.23

Fill out all the required fields, attach necessary documents, sign and click “SUBMIT REFERRAL” below. For questions, please contact your Patient Access Coordinator (PAC).

PATIENT INFORMATION

Referral Type*

New Referral Update or Change to Existing Order Renew Expired Order

Name*

First Name

Last Name

Phone*

Date of Birth*

Address*

Address Line 1

City

State

ZIP Code

Gender*

Male Female

WT (kg)*

HT (in)

Diagnosis*

Any Known Allergies?*

Yes No

List Allergies*

ICD 10 CODE*

LAB WORK

Required lab work*

Required labs and testing are completed and reviewed, okay to proceed with infusion or injection. Attached Labs here or fax to 1-801-931-2631. Lab work not necessary at this time, okay to proceed with infusion or injection. I would like to order lab work.

Lab Attachment #1

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Lab Attachment #2

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Lab Attachment #3

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CLINICAL DOCUMENTATION

I would like to send clinical documentation and insurance information by:*

Fax to 1-801-931-2631 Upload digitally to this form

*Please attach the following: All recent labs and imaging that applies to the treatment. Supporting clinical documentation for the specified ICD 10 Code. Insurance information, Insurance cards if available. (This is necessary to ensure the patient receives maximum insurance benefit.)

Attachment #1

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Attachment #3

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Attachment #5

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Attachment #2

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Attachment #4

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Attachment #6

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PORT FLUSH AND MAINTANENCE

Does the Patient have a port?*

Yes No

IV Port Flush*

Access and De-access implanted port for medication administration, lab draw, and port flush. Flush port with 10ml normal saline after each use and every 3 months when not in use. Do not flush with heparinized solution

In addition to normal saline, Flush port with HEPARINIZED saline solution (Please select one):

In addition to normal saline, Flush port with HEPARINIZED saline solution (Please select one):
	10 u/ml	100 u/ml
3 ml	In addition to normal saline, Flush port with HEPARINIZED saline solution (Please select one):: 3 ml (10 u/ml)	3 ml (100 u/ml)
5 ml	5 ml (10 u/ml)	5 ml (100 u/ml)

Catheter Occlusion:*

Use Cathflo Activase for catheter occlusion: Instill 2mg/2ml in occluded catheter, repeat x1 if no blood return after 120 minutes. Do not use Cathflow Activase for catheter occlusion, notify provider for occlusion.

Other:

Refills*

Order valid for 12 months.

Other:

Total number of infusions or injections.

GLASSIA [Alpha1-Proteinase Inhibitor (Human)] DOSING

Date of last infusion or injection

If no previous administration, leave field blank.

Dosing*

60 mg/kg IV

Frequency*

Once weekly.

Infusion Reaction Protocol Option*

PURE Infusion Reaction Protocol Other Reaction Protocol (please attach)

Click for the PURE Infusion reaction protocol

Attach Reaction Protocol*

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PRESCRIBING PROVIDER INFORMATION

Prescribing Provider*

First Name

Last Name

Provider Phone*

Provider Fax

Address*

Address Line 1

City

State

ZIP Code

Provider Email Address*

Additional Notes

Preparer Name

Preparer Email

This is who will receive the referral confirmation.

Reaction Protocol Consent*

I have read and accept the reaction protocol posted above.

Is Provider available to sign?

Yes, sign directly on this form No, email the provider to sign (Once signed digitally by the provider, the referral will be submitted to Pure)

Physician/Pure Practitioner Signature*

[clear]

Use your mouse or finger to draw your signature above

Date/Time*

:

NPI Number