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Infusion Referral Process

Download and save the appropriate order form; complete, print, and sign the order form; and, fax the signed order form with all additional information needed to our Infusion Coordination team at 405-726-9849.

We will take it from there.  We will perform all preauthorization work, verify the patient’s benefits, schedule the patient’s appointment, and fax a record of the patient’s visit to the referring provider’s office.

1

Download Order Form

  • Download the needed  medication order form from below.

  • ​Save the file before completing it.

2

Complete and Sign

  • Complete the form with the requires information.

  • Sign the completed order form.​

Fax the Order Form

3

  • Gather additional materials listed on the order form.

  • Fax the Order Form with supporting materials.

  •  Fax to 405-726-9849

Order Forms

Please be aware that the patient's insurance "preferred medication" may differ from the name listed below.

Begin typing the medication name in the Search Bar. Or, filter by diagnosis, specialty or both then press apply.

Form Name
Actemra
Adakveo
Aduhelm
Avastin
Benlysta
Cinqair
Durolane
Entyvio
Evenity
Fasenra
Feraheme
Geslyn-3
IVIG
Ilyuma
Injectafer
Iron
Krystexxa
Lemtrada
Leqembi
Nucala
Ocrevus
Onpattro
Orencia
Osteoarthritis
Osteoperosis
Prolia
Remicade
Rituxan
Saphnelo
Simponi Aria
Soliris
Stelara
Supartz FX
Tepezza
Tezspire
Tremfya
Tysabri
Vyepti
Xolair
Zoledronic Acid
Port Flush
Vitamin C
Vitamin B12
IV Fluid
Antibiotics
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