Recommendations, Forms & Templates

IVIg Utilization Management Program Recommendations

Jul 2019

IVIg Request Process 

TMS IVIg Screening Request Form

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 Peripheral Nervous System conditions only.

Jan 2024

Central Nervous System Conditions: IVIg Outcome Questionnaire

To be used for Central Nervous System conditions only.

Sep 2023

Rheumatology Conditions: IVIg 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.