Provider Center
Please send us a completed medication order form, clinical notes, demographics, and the patient’s insurance card, via fax, to (574) 252-7796.
Medication order forms can be found in the table below.
A team member will contact the referring provider and confirm the referral receipt.
We will then take care of any necessary administrative tasks and contact the patient to schedule an appointment.
Medication Order Form
| Infusion Referral Form | Form |
| Vyepti® | Order Form |
| Ocrevus® | Order Form |
| Tysabri® | Order Form |
| Briumvi® | Order Form |
| VYVGART® | Order Form |
| Ultomiris® | Order Form |
| Soliris® | Order Form |
| UPLIZNA® | Order Form |