Submit a Referral

Fax: (888) 219-8102

Download our convenient fillable PDF referral forms for a specific condition or medication below, then simply fax or email to our office along with the necessary patient documentation. We’ll take care of verifying the patient’s insurance coverage and working through the prior authorization process if needed.

Referral Forms | Infusion Protocols

Click on the name of the drug or condition below to download the PDF referral form. Use the search bar to search our list of referral forms.

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FlexCare Infusion Protocol

Please click on any box below to download the protocol PDF document.

Acute Infusion Reaction & Anaphylaxis Treatment Protocol

Flushing and Locking Protocols

Infliximab (including biosimilars) Dose Rounding Protocol

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If you would like to see a referral form that is not listed above, please contact us.