Recommendations, Forms & Templates

IVIg Utilization Management Program Recommendations

Note: The above recommendations are under revision and do not reflect current practice. Effective April 1, 2025, SCIg will be centrally screened for Neurology and Rheumatology Conditions. Follow links for further information on Immunology recommendations for SID and Neurology recommendations for CNS and PNS. 

Jul 2019

IVIg Request Process 

Note: Effective April 1, 2025, panels will begin screening SCIg. 

TMS IVIg Screening Request Form

TMS SCIg Screening Request Form - Provincial panel screening of SCIg conditions is planned to commence April 1, 2025

For centralized screening of IVIg for all Adult Rheumatology conditions, and Neurology conditions as per the Neurology program guidelines

Peripheral Nervous System Conditions: IVIg Outcome Questionnaire

To be used for Non-Approved Adult Peripheral Nervous System conditions only.

Nov 2024

Central Nervous System Conditions: IVIg Outcome Questionnaire

To be used for Adult Central Nervous System conditions only.

Nov 2024

Rheumatology Conditions: IVIg Outcome Questionnaire

To be used for Adult Rheumatology conditions only.

Peripheral Nervous System Conditions: SCIg Outcome Questionnaire

To be used for Non-Approved Adult Peripheral Nervous System conditions only.

Central Nervous System Conditions: SCIg Outcome Questionnaire

To be used for Adult Central Nervous System conditions only.

Rheumatology Conditions: SCIg Outcome Questionnaire

To be used for Adult Rheumatology conditions only.

The following order form templates were developed by PBCO and adopted by Health Authorities as appropriate:

• Secondary Immunodeficiency Ig NEW Request Template
• Secondary Immunodeficiency Ig RENEWAL Request Template
• Physician's Order for IVIg Template
• Physician's Order for IVIg Template - Neurology

PBCO can provide these templates upon request.