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Referral Process

Please always call Novello Infusion to inform staff of referral (231) 252-0893
FAX the following information to: (231) 600-7058

  1. Cover Sheet that includes name and direct phone number of office contact person.
  2. Patient Face Sheet that Includes:
    • Patient physical and mailing address
    • Active phone number
    • Insurance Information
  3. Prior Authorization from Insurance Company
  4. 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
  5. Most recent progress note that includes:
    • Medications
    • Allergies
    • Support for medical necessity of therapy
  6. Most recent lab results as baseline prior to therapy
    • Typically, TB test, Hep Panel, CBC, CMP
    • Iron panel & HGB required for iron infusion
  7. Standing lab orders with frequency


FAX: 231-600-7058

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