Referral Forms
We strive to help make the prescription referral process as easy as possible for prescribers so patients can get the medication they need in a timely manner.Download the appropriate referral form from the list below. Fax completed forms to the number that appears at the top of the form. To streamline this process, we encourage you to e-prescribe by searching for AcariaHealth in your e-prescribe software.
- Asthma Referral Form - Pediatric (PDF)
- Asthma Referral Form - Adult A-N (PDF)
- Asthma Referral Form - Adult O-Z (PDF)
- Breast Cancer Referral Form (PDF)
- Brixadi Patient Enrollment Form (PDF)
- Brixadi Bridge Program Form (PDF)
- CPP Referral Form (PDF)
- Crohn's / UC Referral Form - Pediatric (PDF)
- Crohn's / UC Referral Form - Adult A-Si (PDF)
- Crohn's / UC Referral Form - Adult Sk-Z (PDF)
- Dermatology Referral Form A-G (PDF)
- Dermatology Referral Form H-R (PDF)
- Dermatology Referral Form S-Z (PDF)
- Dificid Referral Form (PDF)
- Dupixent Referral Form (PDF)
- Gastroenterology - Alternative Referral Form (PDF)
- General Injectable Drug Referral Form (PDF)
- Growth Hormone Referral Form (PDF) PLEASE NOTE there is a national backorder affecting the availability of some growth hormone therapies
- HCC/RCC Referral Form (PDF)
- Hepatitis B Referral Form (PDF)
- Hepatitis C Referral Form (PDF)
- HIV/AIDS Referral Form (PDF)
- Makena Auto Injector Referral Form (PDF)
- Melanoma Referral Form (PDF)
- Multiple Sclerosis Oral Referral Form (PDF)
- Multiple Sclerosis Injectable Referral Form A-K (PDF)
- Multiple Sclerosis Injectable Referral Form L-Z (PDF)
- Mycapssa Starter Form (PDF)
- Oncology Infusion Referral Form (PDF)
- Oncology Oral Referral Form (PDF)
- Oncology Urology Referral Form (PDF)
- POMALYST Referral Form (PDF)
- Probuphine Implant Enrollment Form (PDF)
- Pulmonary Arterial Hypertension Referral Form (PDF)
- Remicade Home Infusion Order Form (PDF)
- REVLIMID Referral Form (PDF)
- Rheumatology Referral Form - IV (PDF)
- Rheumatology Referral Form - Non-IV (PDF)
- Rheumatology Referral From - Biosimilars (PDF)
Unbranded Referral Forms
Download forms without any branding or pharmacy information for prescribers in Alabama, Arizona, Arkansas, Colorado, Connecticut, Illinois, Iowa, Louisiana, Maryland, Massachusetts, Minnesota, New Mexico, Pennsylvania, Rhode Island, South Dakota, Vermont, Virginia, West Virginia, Wisconsin and Wyoming