These interactive forms make sending prescriptions to Avella an easy process. Simply download the form, type or print the appropriate information and fax to Avella. We encourage you to e-prescribe to make the process even easier.


Prescription Referral Forms

Immune Globulin prescription referral form

IG (Autoimmune) prescription referral form

Once we receive the completed prescription referral form Avella staff will:

  • Verify insurance coverage (including co-pays) and files the claim with the insurance carrier.
  • Provide prior authorization (PA) and financial assistance (FA) support to ensure patient access.
  • Physician and patient are notified of the status of the prescription within 48 hours of receipt.
  • Avella will contact the patient to coordinate delivery of the medication and to review their support services during the course of therapy.
  • After medication is received, an Avella pharmacy will discuss with the patient their medication(s), anticipated side effects and how to contact the pharmacy with any questions.
  • Avella's specialty care coordinators will be a partner for the patient throughout the course of therapy to maintain adherence, monitor and report side effects, and ensure patient access to available resources.

Download a referral form.