POAC Ferinject Infusion Referral

Date

DayMonthYear
Date
POAC FERINJECT INFUSION REFERRAL FORM

Auckland | Waitematā | Counties Manukau
Refer a Patient for IV Ferinject Infusion:

Use this form to refer a patient for IV Ferinject Infusion to a listed external infusion centre.

Note: If you are a GP or Urgent Care clinic and will be administering the infusion in-house, this form is not required — simply claim via your practice PMS in the usual way. This form is only needed when referring a patient to another provider for the infusion.
Eligibility:

The patient must be eligible for publicly funded primary health care. This is not included in maternity funding package. Please check this before referring.

See Health NZ guide to eligibility HERE

For queries, email claims@poac.co.nz
Patient Funding Eligibility (ALL REQUIRED)
Public Health Funding Confirmation
Patient Residence District
CLINICAL INFORMATION

Note: Special Authority will be required for supply of medication
Phosphate testing requirements
Phosphate
Phosphate MUST be tested prior to referring for this patient
Patient has been diagnosed with anaemia (haemoglobin levels diagnostic of anaemia: Female – Hb lower than 115 g/L (including in pregnancy), Male – Hb lower than 130 g/L) AND ONE OF THE FOLLOWING
Additional required criteria (one of the following)
Ferritin
Haemoglobin
The following haemoglobin levels are diagnostic of anaemia: Female – Hb lower than 115 g/L (including in pregnancy), Male – Hb lower than 130 g/L,
CRP
Patient is pregnant
EDD

DayMonthYear
Date
Weeks gestation
Number of weeks/days (e.g 32.3)
Iron infusion in pregnancy
Name of endorsing specialist
Must be internal medicine physician, obstetrician, gynaecologist or anaesthetist
REFERRAL DETAILS
Date

DayMonthYear
Date
Referred from

Other
Name of referrer
Referrer email
Referrer contact phone
Important: Please ensure referrer contact phone number is included
Enrolled GP practice
Enrolled clinic required for record sharing, clinical safety and continuity of care
GP name
If different to referrer
Will the infusion be given in your own practice?
Preferred Infusion Centre
PATIENT DETAILS
Patient first name
Patient last name
NHI
Date of Birth

DayMonthYear
Date
Gender
Ethnicity
Street address
Suburb
Best contact(s) for patient
Contact phone number and person if not the patient's own number
Patient email
Optional patient will receive emailed copy of referral
Notes
Infusion has been completed
Date of infusion

DayMonthYear
Date
Should be Empty:

POAC FERINJECT INFUSION REFERRAL FORM

CLINICAL INFORMATION

REFERRAL DETAILS

PATIENT DETAILS