Providers

Physician Office Referrals

1. Select a medication from the list below and download the medication paper order form template.
2. You may complete online or by hand.
   1. Select the desired location for treatment.
   2. Complete necessary information in full.
   3. Print and have prescriber sign and date the order.
   4. Fax the completed, signed order form to fax number that corresponds to the location you desire to send patient to be treated (located on header of each order form).
3. Pharmacy Care Advocate will obtain prior authorizations and schedule the patient to receive treatment. You will be contacted should any issues arise.

If the desired therapy is not listed, please send email to OPInfusionDrugOrderCreation@UofLHealth.org with the following information:

1. 1. Drug name.
   2. Indication.
   3. Drug representative name and telephone number, if available.
   4. Number of possible patients on this therapy per month or year.
   5. When this therapy is needed.

The pharmacy staff will begin the process of creating a new order set, contact the drug representative to provide nursing/pharmacy education and build out the order in the electronic medical record system. You will be notified when these tasks are completed so you may complete the new paper medication order.

Contact facility leadership with oversight of Pharmacy Care Advocate or report other concerns by emailing any of the following facility personnel with concerns or questions:

• Whalen@UofLHealth.org
• Knable@UofLHealth.org
• Ryan@UofLHealth.org
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Pharmacy Care Advocate Contact and Fax Information

Order Forms