Make A Referral

Make A Referral

COVID EUA Monoclonal Antibody Therapy

(Click Link Below to Submit Order)

PRESCRIBER ONLINE REFERRAL
PRESCRIBER ORDER FORM

(Use if unable to access Google)

PATIENT SELF-REFERRAL
ROSTER ORDER FORM FOR CONGREGATE SETTINGS
EVUSHELD ORDER FORM

1. Download, Fill In, and Sign the Patient Referral Form

Please download the patient referral form below that meets your needs. Once downloaded, please fill in the form with your patient’s information and sign it. Note: This will include their personal information, diagnosis, premedications and infusion dosage, so please prepare accordingly.

ACTEMRA Form
ADAKVEO Form
BENLYSTA Form
CINQAIR Form
ENTYVIO Form
INFLECTRA Form
IV Antibiotics Form
IV Hydration Form
IVIG (Gammagard) Form
IV Iron Form
KRYSTEXXA Form
NUCALA Form
OCREVUS Form
ORENCIA Form
PROLIA Form
RECLAST FORM
REMICADE Form
RITUXAN Form
SIMPONI ARIA Form
STELARA Form
Therapeutic Phlebotomy
TRUXIMA Form
TYSABRI Form
XOLAIR Form

2. Fax the Completed Form to (510) 969-5840

Once the patient referral form has been completed and signed, please fax the completed form to (510) 969-5840, along with the following information:

  • Patient demographics and insurance information

  • Relevant test results

  • Relevant clinical/progress notes

  • Diagnostic studies supporting primary diagnosis

3. Total Infusion Care Team

The Total Infusion Care Team will take care of authorization for treatment, enrolling patients in drug sponsored financial assistance programs, and patient scheduling.

Thank You for the Referral

If you have any questions for us regarding the referral process, please feel free to reach out using the contact information listed below.

ADDRESS:

Eastmont Town Center 6955 Foothill Blvd, Suite 67A, Oakland, CA, 94605

PHONE:

(510) 878-9528

EMAIL:

 info@totalinfusion.com

BUSINESS HOURS:

Monday – Friday:

8:30am-5:00pm