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Filling out the Elwyn Pharmacy Oncology Infusion Referral Form online is a straightforward process designed to help streamline your referral needs. This guide will provide clear and detailed instructions for each section of the form to ensure a smooth experience for all users.

Follow the steps to complete the Elwyn Pharmacy referral form online

1. Press the ‘Get Form’ button to access the Oncology Infusion Referral Form and display it in your editor.
2. Indicate whether the patient is a current or new patient by checking the appropriate box. Provide today's date for reference.
3. Fill in the patient's personal information, including full name, social security number, date of birth, height, and weight.
4. Enter the patient's address details, including the apartment number, city, state, and zip code. Include the daytime telephone number, cell number, and email address.
5. Select the shipping option for the medication: either 'Ship to Patient at Home', 'Work', or 'Patient will pick up at Physician Office'. Specify the date needed for the medication.
6. List any known allergies and comorbidities of the patient. Include current medications, and if necessary, indicate that a complete list can be faxed.
7. Provide the insured's name and their relationship to the patient. Check whether the patient is eligible for Medicare and if so, provide the Medicare number.
8. Complete the insurance details, including prescription card information such as carrier, telephone, fax, policy/group number, bin number, PCN number, RXID number, and RX group number.
9. Enter the prescriber’s information, including their name, office contact, address, telephone, fax, email, license number, NPI, UPIN, and DEA number.
10. Select the type of cancer being treated and provide the cancer stage. Indicate if the patient has been treated previously for this condition and if they are currently on therapy.
11. List any other medications the patient is taking, including over-the-counter medications. Indicate whether they will stop taking the above medications before starting the new medication and specify the washout period if applicable.
12. Fill in the dosage, quantity, infusion cycles, and refills for each medication needed from the options provided.
13. Complete any information regarding colony stimulating factors or antiemetics as needed, including dosages and quantities.
14. Sign the form in the required section to authorize Elwyn Specialty Care and its employees to serve as your prior authorization designated agent.
15. Fax the completed referral form to Elwyn Specialty Care at 610-545-6030. You may also save or print the completed form for your records.

Complete your Elwyn Pharmacy referral form online today to ensure timely processing.