Infusion Therapy Referrals

Required Documentation

• Signed Provider Order Form
  • Medication name and dosage
  • Frequency and duration of treatment
  • Route of administration
• Patient Demographics
  Include a face sheet or typed document with:
  • Full name
  • Date of birth
  • Address
  • Phone number
  • Emergency contact

• Insurance Information
  Clear copies of the front and back of all active insurance cards (primary and secondary, if applicable).

• ICD-10 Code(s)
  Include the primary diagnosis code(s) relevant to the infusion therapy.

• Clinical/Progress Notes
  Recent provider notes that support the primary diagnosis and medical necessity of the prescribed infusion therapy.

• Supporting Labs or Diagnostic Tests
  Relevant lab results, imaging, or other diagnostic reports that further substantiate the diagnosis and treatment plan.

How to Submit

• Fax:(518) 825-2735

What to Expect

• Our team will verify insurance benefits and obtain prior authorization if needed.
• We will contact the patient directly to schedule their first appointment.
• You will receive confirmation once the patient is scheduled and ongoing updates as needed.

Hematology Referrals

• Referral from your current physician
• Clinical notes relevant to your diagnosis
• Imaging reports including CT, MRI, ultrasound, etc.
• Relevant lab results
• Other test results as applicable to your diagnosis, i.e. genetic testing, bone marrow biopsies report and slides
• Copy of your insurance card(s), Demographic sheet