Referring a Patient for Treatment

To refer a patient to the Provis Infusion Clinic download and complete the patient Referral Form and return to us by fax.

Download & Print the Patient Referral Form Click the link to download, open and print the Provis Infusion Clinic patient referral form in adobe (.pdf) format. The medication order form may also be downloaded and printed and sent in with the referral form (see below). When you have completed the referral form please return it via fax: (416) 532-3635The application will be processed and the patient contacted to review insurance coverage and cost of treatment. When payment issues have been resolved we will notify you as to the date of start of therapy and request completion of a medication order form if one has not yet been completed.Each cycle of therapy will require completion of new Physician Order. It is expected that patients will be reviewed regularly by their treating neurologist before decisions are made about further cycles of treatment.

Important: All orders will be reviewed by a pharmacist and countersigned at the Provis Infusion Clinic by a staff physician prior to starting therapy. In all supporting documents forwarded to the insurer it is important to indicate that the treatment will be delivered in a private clinic outside of a public hospital.

Provis Formulary
No drug will be given at the Provis Infusion Clinic Inc. if it is available and funded in the public system in Ontario for the particular indication and the patient fulfills guideline criteria for public funding.  Provis Infusion Clinic will keep a limited formulary at any given time. We reserve the right to restrict the drugs administered in the Provis Infusion Clinic.

Current Drugs Available – Neurology

Rituxan ® (Rituximab) [order formTo download and print medication order form, click on the link above.

 Physician – Frequently Asked Questions

Q: Can drugs other than those listed on the formulary be given at the Provis Infusion Clinic?
A: At this time only single agent treatments will be administered at the Provis Infusion Clinic. There may be circumstances where patients will require an additional intravenous medication from their treating neurologist. In such cases the treatments will be coordinated and scheduled appropriately.

Q: Who is the “most responsible physician” (MRP)?
A: Provis Infusion Clinic Inc. will be responsible for all aspects of patient care during their time at our clinic. Acute treatment-related issues will be handled by the Provis medical staff with referral to local health facilities as deemed necessary. If complications from treatment arise after leaving the Provis Infusion Clinic patients will be instructed to go to the local emergency room or contact their neurologist/attending MD depending on the urgency of the problem.

Q: What kind of medical record will document the treatment given?
A: A record of infusion is faxed to the referring physician after each treatment at Provis Infusion Clinic. The referring physician also receives a final treatment summary by fax upon completion of the treatment schedule or in case of termination of treatment.

Q: What happens if an “unfunded” drug becomes funded during the time that the patient is attending Provis Infusion Clinic?
A: In keeping with our formulary policy the patient will be informed of the availability of the drug in the public system and will be asked to consult their treating neurologist about continuing a therapy that has been started at Provis Infusion Clinic.

Q: What kind of medical supervision is provided at Provis Infusion Clinic?
A: A physician is present at all times during patient treatment sessions. Medications are administered by experienced nurses, specialized in chemotherapy infusion. Our staff has an average of seven years in-hospital  nursing experience. Emergency procedures and a 911 protocol are established.

Q: What happens if Provis Infusion Clinic declines to treat the patient for medical reasons?
A: If treatment is declined because of poor patient condition or abnormal laboratory results (preventing the administration of an agent), the attending neurologist who referred the patient will be contacted as to the reason for withholding treatment. A written record will accompany the patient on leaving the clinic to be taken to his/her attending rheumatologist. Provis Infusion Clinic Inc. reserves the right not to administer a treatment if felt medically inappropriate.

Q: Does this violate the Canada Health Act?
A: No. Outside of a public hospital patients may purchase medications and have them infused by a service provider.


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