NEUROLOGY ORDER SET

IMPORTANT NOTICE: This order form is intended to be delivered only to the named address and contains material that is confidential, privileged property, or exempt from disclosure under applicable law. If you are not the named addressee, you should not disseminate, distribute, or fill out the form. Please notify the sender immediately and destroy all copies if you have received this document in error.

PATIENT INFORMATION

MEDICAL INFORMATION

THERAPY ORDER

PROVIDER INFORMATION

By signing this form and utilizing our services, you are authorizing Biocare Infusion, and its employees to serve as your prior authorization and specialty pharmacy designated
agent in dealing with medical and prescription insurance companies, and to select the preferred site of care for the patient