- For Providers
- Plans of Treatment
Palmetto Infusion
plans of treatment.
To refer a patient, please choose the appropriate plan of treatment from the list below and fax to 866‐872‐8920, or call 800‐809‐1265 for assistance. Providers can also submit a plan of treatment electronically using the “Upload POTs/Referral Docs” button below.
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Referral Checklist
In addition to a signed and dated Plan of Treatment, please provide the following information to expedite the referral process:
- Diagnosis / ICD-10 diagnosis code
- Most recent history and physical including:
- Current / complete medication list
- Most recent office visit notes
- Past medical history
- Tried and failed therapies
- Allergy history
- Current height / weight
- Drugs and dosing schedule, including last dose and next dose due if applicable
- Most recent lab/test results clinically relevant to therapy. For example: Hep B panel, Calcium and CrCl, PPD Test, etc.
- Insurance information
- Upload POTs/Referral Docs
