Secure Electronic Referral Submission

4 Creek Parkway
Boothwyn, PA 19061
Phone: 866-850-1008
eFax: 877-734-5872
Email: HAIorders @pentechealth.com

Patient Referral Forms

Glycerin Prescription Form

HAI Referral Form

Referral Date

Patient Name

DOB

Clinic Contact

Clinic Phone

Clinic Email

To ensure timely processing, please complete and submit with insurance cards (front & back), recent lab results, and clinical notes

Patient Detail

Please either upload a file or complete the required fields below

Attach Patient Demographics

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Patient Name

Sex

DOB

Parent or Legal Guardian, where applicable

Address

City

State

Zip Code

Phone

Allergies

Height

Weight

Emergency Contact

Relationship

Phone

Insurance Detail

Please either upload a file or complete some of the fields below

Insurance Information attached (including front and back of insurance cards)

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Primary Plan Name	Subscriber Name	DOB
ID #	Group #	Phone

Secondary Plan Name	Subscriber Name	DOB
ID #	Group #	Phone

Prescriber Detail

Prescriber Name
NPI		License #
Address
Phone	Fax	Email	Preferred Communication Method Phone Email Fax

Click box to attach below:

Please upload both a Clinical Note and a Signed Order Form

You are only able to attach a maximum of 20 documents per submission.

Recent Clinical Note

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Signed Order Form

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Order

ICD-10 / Diagnosis Description (select): *

C78.7: Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct

Other

Pump Information

Last Fill Date

Pump Rate

mL/day

Next Fill Date

Current Pump Contents: *
Glycerin Heparinized Saline Floxuridine

Referral to Pentec Health to fill the pump with the following:

	Product *	Directions
	Sterile Glycerin 50% v/v Solution	RN to instill 30mL into implanted Intera 3000 pump to maintain catheter patency

Attach the signed prescription

If you are unable to upload supporting documentation above, you can still sign and submit the referral form by selecting "Submit" below and faxing supporting documentation to Pentec at 877-734-5872.

Patient Referral Comments

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