Order Forms - Submit a Referral

Making a referral is hassle free and easy. All you have to do is submit your patient’s orders and insurance information and Pure Infusion Suites will handle the rest!

Please use the General Referral Form below for drugs not listed below:

General Order Form

Reaction Protocols (*Required for each patient order below):

Hypersensitivity Order Set

Please use this form when adding information to a previous referral.

Supplemental Order Form

New Online Forms

Our new online forms will help improve the referral process for our partners and expedite the pre authorization process ensuring that your patients receive prompt treatment.

Please contact us to inquire about treatments not listed below.

Actemra Referral Form

Required Clinicals:

  • TB test
  • Baseline CBC
  • Liver panel
  • Lipid panel

Aduhelm Referral Form

Required Clinicals:

  • Confirmation of the presence of amyloid beta pathology

Avsola Referral Form

Required Clinicals:

  • TB test
  • Hep B screening

Benlysta Referral Form

Required Clinicals:

  • Assess for depression and suicidality

Briumvi Referral Form

Required Clinicals:

  • Hep B screening
  • Quantitative serum immunoglobulins

Cerezyme Referral Form

Cimzia Referral Form

Required Clinicals:

  • TB test
  • Hep B screening

Entyvio Referral Form

Evenity Referral Form

Required Clinicals:

  • Calcium level
  • DEXA screening

Fasenra Referral Form

Feraheme Referral Form

Required Clinicals:

  • CBC
  • Iron Studies

Glassia Referral Form

IVIG Referral Form

Required Clinicals:

  • For Primary immunideficiency (Pl): Obtain lgG trough levels frequently to guide dose

Ilaris Referral Form

Required Clinicals:

  • TB test

Ilumya Referral Form

Required Clinicals:

  • TB test

Ixifi Referral Form

Required Clinicals:

  • TB test
  • Hep B Screening

Krystexxa Referral Form

Required Clinicals:

  • Uric acid level before initiation and within 48 hours prior to each infusion
  • G6PD deficiency screening

Lab Order Form

Leqembi Referral Form

Required Clinicals:

  • MRI Prior to 1st (Within the last year) 5th 7th and 14th dose

Leqvio Referral Form

Nucala Referral Form

Ocrevus Referral Form

Required Clinicals:

  • Hep B Screening
  • Quantitative immunoglobulin

Orencia Referral Form

Required Clinicals:

  • TB test
  • Hep B screening

Port Flush Order Form

Prolia Referral Form

Required Clinicals:

  • Calcium level

Remicade Referral Form

Required Clinicals:

  • TB test
  • Hep B screening

Renflexis Referral Form

Required Clinicals:

  • TB test
  • Hep B screening

Rituxan Referral Form

Required Clinicals:

  • Hep B screening

Ruxience Referral Form

Required Clinicals:

  • Hep B screening

Saphnelo Referral Form

Simponi Aria Referral Form

Required Clinicals:

  • TB test
  • Hep B screening

Skyrizi Referral Form

Required Clinicals:

  • TB test
  • Liver enzymes and bilirubin

Stelara Referral Form

Required Clinicals:

  • TB test

Steroid Referral Form

Tepezza Referral Form

Tezspire Referral Form

Tysabri Referral Form

Required Clinicals:

  • Hep B screening
  • JCV

Vyepti Referral Form

Vyvgart Referral Form

Xolair Referral Form

Required Clinicals:

  • Serum lgE levels

Zoledronic Acid Referral Form

Required Clinicals:

  • Serum Ca levels
  • Creatinine clearance and serum creatinine prior to each dose

Oncology Forms

Easy Referral Process

1

Referral form

  • Complete the appropriate referral form above
  • Attach all required insurance information, clinical notes, and labs
2

Pre-authorization

  • The Pure intake team works directly with insurance providers to receive pre-authorization of treatment
  • Patient Access Coordinator (PAC) will contact the patient to set expectations for the pre-authorization process that usually takes 7 business days or less
3

Appointment scheduling

  • After pre-authorization approval, PACs schedule an appointment with the patient and educates on infusion preparation
  • PACs will also help patients with available financial assistance programs
4

Infusion day

  • At Pure Infusion Suites, we are “patient obsessed!” The infusion experience includes snacks, drinks, meals, comfortable private rooms with a 55” TV, WIFI, and room for children, friends or family to keep them company
5

Post-infusion

  • A nurse will follow up and check on the patient within 24 hours of their infusion
  • PACs will send the infusion notes to the provider

PDF Forms

You have the option to utilize the fillable PDF referral forms provided below. These forms can be filled electronically using Acrobat or printed and filled manually. Once completed, you can fax the form to 1-801-931-2631.

If you need help with your referral, please visit the location page you would like to reach and speak with our local Patient Access Coordinator (PAC).

Locations