Tepezza

Referral Guide

The following guide lists the information we need to ensure a quick, seamless patient referral for a Tepezza infusion treatment.

All referrals must include:

• Order
• Patient Demographics
• Supporting Clinicals (Notes and Labs)

Order Information:

• Provider name
• NPI#
• Address
• Phone/Fax
• Provider signature (or electronically authenticated signature)

Patient Demographics:

• Patient name
• Phone number
• Address
• Insurance information (primary and secondary if applicable)

Supporting Clinicals (Notes and Labs):

• Clinicals to support one or more of the following:
• Thyroid Eye Disease
• Diagnosis code of E05.00

Ready to make a referral?
Download our referral form.