Subcutaneous Immune Globulin Patient Information Prescriber + Shipping Information Patient Name: _______________________________ DOB: _____________ Sex: Female Male SSN: ______________________________________ Language: ________________ Wt:______ kg lbs Ht:______ cm in Address: ______________________________________________________ Apt/Suite: ________ City:____________________ State:______ Zip:______ Phone:____________________ Alternate Phone:______________________ Caregiver name: _________________________ Relation: _______________ Local Pharmacy: _________________________ Phone: ________________

Prescriber Name:_______________________________________________ NPI: _______________________________________________________ Address: _____________________________________________________ Apt/Suite: _______ City:____________________ State:______ Zip:______ Contact: ______________________________________________________ Phone: ________________________ Alternate: ______________________ Fax: _________________________________________________________ Email address: ________________________________________________ If shipping to presciber: First Fill Always Never

Insurance Information (Please fax a copy of front and back of the insurance cards) 1˚ Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________ 2˚ Insurance Plan: _____________________ Plan ID # ___________________ Policy Holder: ___________________________ Relation: ______________

Clinical Information (Please fax all pertinent clinical and lab information) Diagnosis Code(s): _____________________________________________________________________________________________________________ Date of Diagnosis: _______________________________________________ IgA deficiency: Yes No IgA level _________ mg/dL Date:___________ IgG trough:______mg/dL Date:______ Diabetic: Yes No

Has patient received immune globulin previously? Yes No If yes, product information: _______________________________________ Date of last infusion: ____________ Date of next infusion: ______________

Comorbidities: __________________________________________________________________________________________________________________Concomitant Medicatons: _________________________________________________________________________________________________________Allergies: NKDA Other: _____________________________________________________________________________________________________

Prescription Drug Dose and Directions Quantity Refills

Immune Globulin Products Hizentra

® 20%

Weekly SC dose = IVIG Dose (g) x 1.37 / IVIG weekly interval originally given

HyQvia® 10%

Weekly SC dose = IVIG Dose (g) x 1.37 / IVIG weekly interval originally given

Other Medications

Acetaminophen ______mg Premedication 30 minutes prior to infusion. Post infusion every 4-6 hours as needed for fever/headache.

Diphenhydramine ______mg Premedication 30 minutes prior to infusion. Post infusion every 4-6 hours as needed for itching/site

Drug: _______________________ Strength: ______________ Quantity to dispense: ______________________

Anaphylaxis Order and Medication

Orders: 2. Call 911 and prescribing physician 3. Administer medications below as per protocol

Ancillary Supplies & Equipment

Syringe driver/pump(s) and supplies provided as needed for administration and appropriate disposal of infusion materials.

Skilled Nursing Visits

To train patient/caregiver in Subcutaneous Immune Globulin administration, provide education related to disease state/therapy and assess general status. Typically 2-4 training visits required. Once trained and able to return demonstrate, patient/caregiver to self-administer Subcutaneous Immune Globulin medication independently unless otherwise specified.

Administration procedures to be followed per pharmacy protocol. Per state-specific law, prescriptions will be dispensed as generic, if applicable, unless notated otherwise: _______________________________________

Prescriber’s Signature:__________________________________________________________________________________ Date: _________________ I authorize Diplomat Pharmacy, Inc. and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any

future fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Diplomat Pharmacy, Inc.

Confidentiality Statement: This message is intended only for the individual or entity to which it is addressed. It may contain information which may be proprietary and confidential. It may also contain privileged, confidential information which is exempt from disclosure under applicable laws, including the Health Insurance Portability and Accountability Act (HIPAA). If you are not the intended recipient, please note that you are strictly prohibited from disseminating or distributing this information (other than to the intended recipient) or copying this information. If you received this communication in error, please notify the sender immediately by calling 810.768.9178 or by emailing compliance@diplomat.is to obtain instructions as to the proper destruction of the transmitted material. Thank you. Copyright © 2017 by Diplomat Pharmacy Inc. All rights reserved. Diplomat is a registered trademark of Diplomat Pharmacy Inc. 06092017

Cuvitru 20%Number of sites: __________ Rate: Per manufacture guidelines, as tolerated __________________

Weekly SC dose = IVIG Dose (g) x 1.3 / IVIG weekly interval originally given

Please complete and attach HyQvia Prescription Referral form which can be located at: http://www.hyqviahcp.com/pdf/PatientRxStartForm.pdf

Quantity: 2 Administer 0.15 mg (15 - 30 kg) IM or subcut as needed Administer 0.3 mg (≥ 30 kg) IM or subcut as needed

Refills: _____Epinephrine Auto-injector

Gamunex-C®

Directions: _____________________________________________________________________ Refills: __________ The quantity and refills for pre-treatment and flushing protocol medications will match the primary therapy administration requirements.

Number of sites: __________ Rate: Per manufacture guidelines, as tolerated _________________

Gammaked™ 10%

Gammagard liquid® 10%

Number of sites: __________ Rate: Per manufacture guidelines, as tolerated _________________

1. Stop infusion

Stamp signature not allowed, physician signature required.

Lidocaine 2.5% and Prilocaine 2.5% Cream 30 grams. Apply small amount topically to insertion site(s) prior to needle insertionas needed.

reactions.

http://www.hyqviahcp.com/pdf/PatientRxStartForm.pdf

Patient Name: DOB: Prescriber Name: NPI: Wt: Address: Address_2: AptSuite: City: Zip: Contact: AptSuite_2: City_2: Zip_2: Phone: Alternate: Phone_2: Alternate Phone: Fax: Caregiver name: Relation: Email address: Local Pharmacy: Phone_3: fill_30: Plan ID: Policy Holder: Relation_2: fill_34: Plan ID_2: Policy Holder_2: Relation_3: ICD10Diagnosis Code: Date of Diagnosis: No IgA level: mgdL Date: If yes product information: IgG trough: mgdL Date_2: Date of last infusion: Date of next infusion: Other: Take_2: Drug: Strength: Qty: Directions: Refills: Date: State-Pt: [ ]State-MDO: [ ]Reset Form: GenericSignature: Male: OffWt-kg: OffWt-lbs: OffHt: Ht-cm: OffHt-in: OffFirst: OffIgA-Y: OffIgA-N: OffAll-NKDA: OffAll-Other: OffDM-Y: OffDM-N: OffPT-Y: OffPT-N: OffHyQvia: OffGammaKed: OffPatientTrain: OffFemale: OffSS#: Language: Always: OffNever: OffHizentra: OffComorbidities: Concomitant Meds: Cuvitru: OffCuvitruDirections: OffGammakedDirections: OffGammagardLiquidDirections: OffGamunexDirections: OffGamunex: OffGammagardLiquid: OffEpi0: 3: Off

Epi: 15: Off

Supplies: OffDirectionsCuvitru: Take: DirectionsHizentra: DirectionsGammaked: DirectionsGammagardLiquid: DirectionsGamunex: Qtyhizentra: RefillsCuvitru: RefillsHizentra: QtyGammaked: RefillsGammaked: QtyGammagardLiquid: RefillsGammagardLiquid: QtyGamunex: RefillsGamunex: EpiRefills: CuvitruRate: OffHizentraRate: OffGammaRate: OffHizentraDirections: OffCuvitruAsTol: OffHizentraAsTol: OffGammaAsTol: OffQtyCuvitru: HizAsTol: GamAsTol: CuvAsTol: CuvSites: HizSites: GammaSites: AcePre30: OffAcePre3-6: OffDiphPre3-6: OffPharmacy: [--Select One--]TollFreePhone: PhoneTollFreeFax: FaxSPOC Name: Insert Sales Contact Name (if known)DiphPre30: OffLidocaine: Off