Guidelines  Dated

IVIG Utilization Management Program Guidelines

Jan 2017

TMS IVIG Request Process Dated

IVIG Request Process 

Jan 2017
 Forms & Templates
Dated

TMS IVIG Screening Request Form

For TMS use when a Physician's Order for IVIG Form is received for a patient whose condition is not on the List of Approved Medical Conditions for IVIG use as outlined in the IVIG Utilization Management Program Guidelines, or who is a rheumatology patient over 18 years of age.

Jan 2017

Physician's Order for IVIG Template

To be used as a template for Health Authority Physician IVIG Order Forms. Conditions listed are approved for use of IVIG in BC.

Jan 2017

IVIG Outcome Questionnaire Template

To be used for all conditions, excluding Rheumatology and Non-Approved Neuromuscular. 

Jan 2017

IVIG Outcome Questionnaire for Adult Non-Approved NEUROMUSCULAR Conditions

This template is to be used for Adult Non-Approved Neuromuscular conditions only.

Revised 

Jan 2017

IVIG Outcome Questionnaire for Adult RHEUMATOLOGY Conditions

This template is to be used for Adult Rheumatology conditions only.

Revised

Jan 2017

IVIG Dosing Information for Ordering Physicians Template

Can be used as a communication tool to explain IVIG Dosing based on Adjusted Body Weight Calculation to ordering Physicians.

Jan 2017

IVIG Hemolysis Letter Template

Can be used as a communication tool to explain the risk of hemolysis in high dose IVIG therapy in group A, B, and AB patients.

 Jan 2017

TMS IVIG Request Process