Gunnison Valley Health Cancer Care Center
NPI: 1932109048 | Tax ID: 846008116 | Fax: 970-642-4774
Ocrevus Infusion Order (Maintenance Dose)
We need the following information in order to best serve your patient and provide safe care.
Date
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Month
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Day
Year
Date
Treatment Location
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Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Allergies
*
Weight
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lbs
kg
Height
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in
cm
Diagnosis and/or ICD-10
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Prior Authorization #
*
Must be initiated by referring provider's office. NPI: 1932109048 | Tax ID: 846008116
PRE-MEDICATIONS
(30 minutes before infusion)
Solu-Medrol:
125mg
IV
Diphenhydramine:
50mg
IV
PO
Acetaminophen:
1000mg
PO
OCREVUS (OCRELIZUMAB) IV MAINTENANCE DOSAGE:
Date of Last Treatment, if Continuation
-
Month
-
Day
Year
Date
600 mg in 500 mL 0.9% Sodium Chloride 6 months after loading dose then every 6 months
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