• Signed order from the referring provider
• Medication name, dosage, frequency, and duration
• Route of administration

• Full name, date of birth, address, and phone number
• Emergency contact information

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

• Relevant ICD-10 code(s) supporting the infusion therapy

• Recent provider notes supporting the primary diagnosis and medical necessity of the prescribed treatment

• Relevant lab results, imaging, or other diagnostic reports that substantiate the diagnosis and treatment plan

Submission Instructions

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.

Hematology Referrals

Required Documentation

• Referral from the patient’s current physician
• Clinical notes relevant to the patient’s diagnosis
• Imaging reports (CT, MRI, ultrasound, etc.)
• Laboratory results and other diagnostic tests, including genetic testing or bone marrow biopsy reports and slides, if applicable
• Patient demographics (full name, date of birth, contact information)
• Insurance information (front and back copies of all active insurance cards)

Submission Instructions

Next Steps