Tysabri

The following guide lists the information we need to ensure a quick, seamless patient referral for a Tysabri 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:
  • Patient has relapsing-remitting multiple sclerosis (RRMS)
  • Patient has moderately to severely active Crohn’s disease (CD) who had an inadequate response to, or was unable to tolerate, conventional CD therapies and inhibitors of TNF
  • JCV results

Ready to make a referral?
Download our Tysabri Order Form.