Refer a Patient to PeaceHealth Cancer Infusion Center in Vancouver or Longview

If you are not a PeaceHealth Medical Group provider, the following elements are required before we can process your order and schedule your patient for treatment.

• Recent progress note from the ordering provider
• Relevant laboratory results and/or other supporting documentation
• Prior Authorization is required to be obtained and maintained by the ordering provider’s office
• Insurance documentation with the prior authorization letter or reference number
• Valid order (Please use the PeaceHealth-approved paper order)

Remember to include the following information when filling out a paper order:

• Select infusion center location
• Patient name AND date of birth
• Date of order issuance
• ICD-10 code AND Dx description
• Check the boxes of ALL orders you would like to activate
• Provider name (printed) at the bottom of each page of orders
• Provider signature AND date of signature at the bottom of each page of orders
• Name and contact information of the provider that will be following this patient (if different than the ordering provider)
• For blood products, contact the Infusion Intake Coordinator at 360-514-2005
• Completed PeaceHealth Infusion Order Form – with special attention to the “Provider Communication Orders”

Fax the order form to the location you are referring to: