IVIG Utilization Management Program Recommendations

July 2019

IVIG Request Process 

TMS IVIG Screening Request Form

For TMS use when a Physician's Order for IVIG Form is received for a patient whose condition is not on the List of Approved Medical Conditions for IVIG use as outlined in the IVIG Utilization Management Program Guidelines, or who is a rheumatology patient over 18 years of age.

Physician's Order for IVIG Template

To be used as a template for Health Authority Physician IVIG Order Forms. Conditions listed are approved for use of IVIG in BC.

IVIG Outcome Questionnaire Template

To be used for all conditions, excluding Rheumatology and Non-Approved Neuromuscular. 

IVIG Outcome Questionnaire for Adult Non-Approved NEUROMUSCULAR Conditions

This template is to be used for Adult Non-Approved Neuromuscular conditions only.

Jan 2017

IVIG Outcome Questionnaire for Adult RHEUMATOLOGY Conditions

This template is to be used for Adult Rheumatology conditions only.

June 2018

IVIG Dosing Information for Ordering Physicians Template

Can be used as a communication tool to explain IVIG Dosing based on Adjusted Body Weight Calculation to ordering Physicians.

IVIG Hemolysis Letter Template

Can be used as a communication tool to explain the risk of hemolysis in high dose IVIG therapy in group A, B, and AB patients.