To refer a patient, please send us an order form or a prescription including the required information listed below. Once the form is completed, you can upload the information online or fax it to 800-540-1852.
e-Prescriptions are accepted.
Required Information Checklist
- Diagnosis Code/Date of Diagnosis
- History of Treatment
- Failed Medications/Therapies
- Previous Lab Work (Date of Last TB Test/HBV Test)
- Any Other Pertinent Information supporting Patient’s Treatment Plan
- Full Legal Name
- Email and Phone Number
- Insurance Card (Front and Back)