Infusion orders
ORENCIA (abatacept)
Date
01
/
12
/
2025
Choose a location
Franklin, TN
Franklin, TN
REFERRAL STATUS
New Prescription
Order Renewal
Dosage or Frequency Change
Discontinuation of Order
Other:
PATIENT INFORMATION
Patient Name
Address
Sex
M
F
Date of Birth
MM
/
DD
/
YYYY
Allergies
NKDA
Other:
NPI
Phone number
Tax ID
Insurance Carrier (Primary)
Primary Insurance ID Number
Insurance Carrier (Secondary)
Secondary Insurance ID Number
PHYSICIAN INFORMATION
Referral Coordinator Name
Order Provider
Referral Coordinator Email
Provider NPI
Referring Practice Name
Phone
Practice Address
Fax
City
State
Zip Code
DIAGNOSIS
Rheumatoid Arthritis
Polyarticular Idiopathic Arthritis > 6 yro (PJIA)
Other:
Please provide ICD-10 code:
PRE-MEDICATION
Tylenol 1000mg PO
Solu-Cortef 100mg IVP
Cetirizine 10mg PO
Diphenhydramine 25mg IVP
Diphenhydramine 25mg PO
Other:
Solu-Medrol 125mg IVP
ORENCIA ORDERS
DOSAGE
500mg
750mg
1000mg
Other:
FREQUENCY
Induction: Week 0, 2, 6, then every 8 weeks
Every 6 weeks
Every 8 weeks
Other:
PATIENT WEIGHT
Lbs./Kg
NOTES
Supporting Documentation
Please upload applicable supporting documentation such as:
-Recent Labs
-Progress Notes
-Physical Prescription
-Demographics
-Insurance
-Other Useful Documentations
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ORDER PROVIDER
Signature
Clear
Verification
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