Specialty Infusion Centers primarily administers specialty biologic infusions and injections for patients with chronic conditions. Completed order forms can be emailed to rx@specialtyinfusion.com, uploaded or faxed to 800-540-1852. Click the button for the desired therapy below and the form will begin to download automatically. To refer a patient on a therapy not listed below please utilize our General Referral Form. Please call 212-776-9090 with any questions.
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Required Information Checklist
Clinical Records
- Diagnosis Code/Date of Diagnosis
- Height/Weight
- History of Treatment
- Failed Medications/Therapies
- Previous Lab Work (Date of Last TB Test/HBV Test)
- Any Other Pertinent Information supporting Patient’s Treatment Plan
Patient Information
- Full Legal Name
- Email and Phone Number
- DOB
- Address
- Insurance Card (Front and Back)
