Now Accepting ReferralsPhone: (774) 581-0032   |   Fax: (774) 581-0033

Provider Order Forms

Search all 31 GBIC referral and prescribing order forms by specialty, medication, or generic name.

For referring providers: Select the appropriate form, complete the referral checklist and prescribing order, and include the requested supporting clinical and insurance documentation. Completed referral packets may be faxed to (774) 581-0033.

Rheumatology & Autoimmune

Biologic and immune-modulating therapy order forms.

6 forms

Actemra

tocilizumab or biosimilar
Referral checklist + prescribing order • Fillable PDF

Neurology

Neurologic specialty therapy order forms.

8 forms

Ocrevus / Ocrevus Zunovo

ocrelizumab
Referral checklist + prescribing order • Fillable PDF

Vyvgart IV / Vyvgart Hytrulo

efgartigimod
Referral checklist + prescribing order • Fillable PDF

Gastroenterology

GI and inflammatory bowel disease therapy order forms.

4 forms

Infliximab

infliximab / biosimilar
Referral checklist + prescribing order • Fillable PDF

Skyrizi IV Induction

risankizumab-rzaa
Referral checklist + prescribing order • Fillable PDF

Hematology & Iron Therapy

Iron and hematology-related therapy order forms.

1 form

Bone Health & Endocrinology

Bone health and osteoporosis therapy order forms.

2 forms

Evenity / Prolia

romosozumab / denosumab
Referral checklist + prescribing order • Fillable PDF

Zoledronic Acid

zoledronic acid
Referral checklist + prescribing order • Fillable PDF

Immunology / Allergy / Specialty Biologics

Immunoglobulin and selected specialty biologic order forms.

3 forms

Intravenous Immunoglobulin (IVIG)

IVIG
Referral checklist + prescribing order • Fillable PDF

Other Specialty Therapies

Additional specialty medication and injection order forms.

7 forms

IV Solumedrol

methylprednisolone
Referral checklist + prescribing order • Fillable PDF

Vitamin B12 Injection

cyanocobalamin
Referral checklist + prescribing order • Fillable PDF
No matching order forms found. Try another medication, generic name, or specialty.

Can't find the form you need?

Contact Greater Boston Infusion Center at (774) 581-0032 or fax referral information to (774) 581-0033.