Gazyva

Instructions

1 – Please open authorization forms (above). Fill out the forms on your computer, save and print.

2 – Open Physician Orders for the office of your choice (at left). Save to your computer, print and fill out.

3 – The following tests should be performed and test results faxed to Pacific Infusion before the patient’s first visit: Need Hep B, HBsAG and anti-HBc

4 – Send list of medications tried and failed.

5 – Fax the following to Pacific Infusion Center (310) 297-9222:

ㅤ• Completed and signed forms/order

ㅤ• Copy of the patient’s insurance card(s)

ㅤ• Demographics

ㅤ• OV notes

ㅤ• Tried and failed medications

ㅤ• Labs

ㅤ• Drug Enrollment Forms

6 – After the patient’s infusion appointment, our nurses will fax a copy of the infusion notes to your office.