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.
- ADBRY Referral Form (PDF)
- 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-Q (PDF)
- Crohn's / UC Referral Form - Adult R-T (PDF)
- Crohn's / UC Referral Form - Adult U-Z (PDF)
- Gastroenterology - Alternative Referral Form (PDF)
- General Injectable Drug Referral Form (PDF)
- Growth Hormone Referral Form (PDF)
- HCC/RCC Referral Form (PDF)
- Hepatitis B Referral Form (PDF)
- Hepatitis C Referral Form (PDF)
- HIV/AIDS Referral Form (PDF)
- Iclusig Referral Form (PDF)
- Injectafer Referral Form (PDF)
- IQIRVO Enrollment Form (PDF)
- IVIG Referral Form (PDF)
- Makena Auto Injector Referral Form (PDF)
- MASH 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)
- OHTUVAYRE Referral 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)
- REZDIFFRA Referral Form (PDF)
- Rheumatology Referral Form - IV (PDF)
- Rheumatology Referral Form - Non-IV (PDF)
- Rheumatology Referral Form - Non-IV BIOSIMILAR (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