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PHONE: 855.859.1738 FAX: 844.443.7933 Pharmacy Services Department Pharmacy Services INTRAVENOUS & SUBCUTANEOUS IMMUNE GLOBULIN (IVG & SCI)Department Prior Authorization Form Standard Request (72
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Immune globulins - prior are antibodies that provide passive immunity against specific antigens.
Healthcare professionals or institutions administering immune globulins - prior are required to file.
Immune globulins - prior can be filled out by providing information on the patient, the specific antibodies administered, and the administering healthcare professional.
The purpose of immune globulins - prior is to boost the immune system and provide protection against certain infections.
Information such as patient demographics, dosage administered, administration route, and any adverse reactions must be reported on immune globulins - prior.
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