For Providers

Referral Forms

Infusion & Injection Therapy Order Forms
, Referral Forms, Healix Infusion Care

Healthcare providers can use the below referral forms to submit a patient order.

Completed order forms and supporting clinical documentation can be faxed to (833) 786-0025 or uploaded to our secured portal. We’ll take care of the rest. Questions? Give our team a call at (800) 958-4042. We’re happy to help!

Biologic Referral Forms

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Actemra®

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Amvuttra®

P

Asceniv™

P

Avsola®

P

Benlysta

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Bivigam®

P

Briumvi®

P

Cimzia®

P

Cinqair®

P

Cosentyx® IV

P

Cutaquig®

P

Cuvitru®

P

Entyvio®

P

Evenity®

P

Fasenra®

P

Feraheme®

P

Gammagard®

P

Gamunex® -C

P

General Order

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Hizentra®

P

Hyqvia

P

INFeD®

P

Inflectra®

P

Injectafer

P

IV Iron

P

IVIg

P

Krystexxa®

P

Lemtrada®

P

Leqembi®

P

Leqvio®

P

Migraine Cocktail

P

Monoferric

P

Nucala®

P

Ocrevus®

P

Octagam®

P

Omvoh™ IV

P

Onpattro®

P

Orencia®

P

Panzyga®

P

Prolia®

P

Reclast®

P

Remicade®

P

Renflexis®

P

Riabni®

P

Rituxan®

P

Ruxience®

P

Rystiggo®

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Saphnelo®

P

Simponi Aria®

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Skyrizi® IV

P

Soliris®

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Solu-Medrol®

P

Stelara® IV

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Tepezza®

P

Tezspire™

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Truxima®

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Tysabri®

P

Ultomiris®

P

Uplizna®

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Venofer

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Vyepti®

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Vyvgart®

P

Xolair®

Infectious Disease Referral Forms

Therapies Available in All Regions
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Apretude®

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Cabenuva®

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Dalvance®

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Kimyrsa®

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Pemgarda™

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Rezzayo™

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Zinplava®

Antimicrobial Therapies (not available in Pennsylvania)
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Cefazolin

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Cefepime

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Ceftriaxone

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Daptomycin

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Ertapenem

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IV Antimicrobials

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Meropenem

P

Nuzyra®

P

Piperacillin-Tazobactam

Wellness & Hydration Referral Forms

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Hydration, Electrolytes, and Anti-Emetics

To inquire about a specific therapy not listed above, contact us.

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