Referral Forms by Specialty

Referring Your Patient is Easy!
Patients can quickly and easily be referred by one of the options below. Once your referral is received, an Intake Coordinator will contact you to complete the process.

Complete a MedRx referral form online and print it for the prescriber’s signature. Enter the patient, prescriber, diagnosis and medication. The form retrieves the prescriber’s details from the NPI Registry and suggests the labeled dose and directions for the diagnosis. Every entry can be edited before printing.

MedRx does not store or save any information entered in the form. Fax the signed form with supporting documentation to (844) 671-2601.

The Online Form, start to finish, in 25 seconds. It has music and no narration; the text version below has everything it shows.

Text version of the video

A blank Gastroenterology referral form, and the question “Referring a patient for home infusion or specialty medication?”
On the homepage, “Send a referral” opens this page at the Online Form tab, and “Fill out a referral form” opens the form.
The form looks up the prescriber by NPI, matches the ICD-10 code to MedRx’s formulary, and offers the labeled dose for the diagnosis. The example uses code K50.112 and Remicade (infliximab).
The finished form prints as one page: print it, sign it, and fax it to (844) 671-2601. Make sure to include lab results, the last visit note, the patient’s insurance, and the patient’s demographics with height and weight.
“Nothing you type is sent to us or saved.” The video closes on “Send a referral” and medrxinfusion.com/quick-referral.

The patient and the prescriber in the video are fictional, and so is the NPI.

Watch on YouTube

DOWNLOAD REFERRAL FORMS:

Connect with MedRx

Share your contact information, and our specialists from the MedRx Infusion team will reach out to you to discuss home infusion and specialty pharmacy care. Only a contact name and phone number are required; additional clinical and insurance details help us begin the intake process sooner.

Key facts

Organization: MedRx Infusion Clinical Pharmacy
What we do: A home infusion pharmacy and specialty pharmacy, with infusion nurses who visit patients at home and a pharmacist on call 24 hours a day, 7 days a week.
Where: Pharmacy at 417 N Oak St, Inglewood, CA 90302. Licensed in 44 states, the District of Columbia and Puerto Rico. See every place we serve
Accreditation: URAC (Specialty Pharmacy) and ACHC (Accreditation Commission for Health Care).
Phone, 24 hours: (844) 671-2600
Fax: (844) 671-2601

Accurate as of October 19, 2026

Send a referral

Intake handles benefits investigation, prior authorization and scheduling.

Send a referral

Phone

(844) 671-2600

Speak with an intake coordinator

Fax

(844) 671-2601

Send a completed referral form

Forms

Referral forms

Specialty-specific PDFs

Referral Forms by Specialty

DOWNLOAD REFERRAL FORMS:

Immunoglobulin Referral Form

Neurology Referral Form

Multiple Sclerosis Referral Form

Migraine Referral Form

Gastroenterology Referral Form

Allergy and Asthma Referral Form

Hepatitis C Referral Form

Hepatitis B Referral Form

Rheumatology Referral Form

Osteoporosis Referral Form

Nephrology Referral Form

Oncology Referral Form

Iron Infusion Referral Form

Hemophilia Referral Form

Dermatology Referral Form

Connect with MedRx

Key facts

Send a referral