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:
Reaction Protocols (*Required for each patient order below):
Please use this form when adding information to a previous referral.
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.
Required Clinicals:
Required Clinicals:
Required Clinicals:
Required Clinicals:
Required Clinicals:
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).