Please always call Novello Infusion to inform staff of referral (231) 252-0893
FAX the following information to: (231) 600-7058
- Cover Sheet that includes name and direct phone number of office contact person.
- Patient Face Sheet that Includes:
- Patient physical and mailing address
- Active phone number
- Insurance Information
- Prior Authorization from Insurance Company
- Complete Order for Therapy which includes:
- Patient name
- Patient birth date
- Diagnosis including ICD-10 code(s)
- NOTE: iron orders always need a primary AND a secondary diagnosis such as iron deficiency anemia & malabsorption (or the cause of the anemia)
- Drug information:
- Drug to be administered
- Dose
- Route
- Specific frequency of therapy – cannot state “maintenance”
- Duration (usually 1 year if ongoing therapy)
- Pre-medications if necessary
- Emergency medications or may state per Novello Infusion Policy
- If requesting therapy administration through a patient’s central line, please state
- Physician/Provider NPI, signature, date
- NOTE: Signature stamps are not accepted by insurance companies
- Most recent progress note that includes:
- Medications
- Allergies
- Support for medical necessity of therapy
- Most recent lab results as baseline prior to therapy
- Typically, TB test, Hep Panel, CBC, CMP
- Iron panel & HGB required for iron infusion
- Standing lab orders with frequency
FAX: 231-600-7058
