Oncology / Physician Referral

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 button to download, open and print the Provis Infusion Clinic patient referral form in adobe (.pdf) format. When you have completed the referral form please return it via fax: (416) 532-3635.  Also, a Medication Order Form (MOF – listed below) will be needed to be completed and faxed to Provis, either with the original referral form or shortly before treatment is to be initiated.    

The patient will be contacted directly to discuss insurance coverage and cost of treatment and start date. 

Each cycle of therapy requires the completion of a new Medication Order as it is expected that patients will be reviewed regularly by their treating oncologist prior to each cycle of therapy.

Important: All medication orders are reviewed by a pharmacist and reviewed 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.  Most recent bloodwork will be needed to be faxed to Provis before each cycle or treatment depending on the medication. 

Provis Formulary
No drug will be given at the Provis Infusion Clinic 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.

Current Drugs Available:
To download and print specific medication order form, click on the link next to the medication.

• Abraxane™ Order Form & Information
• Adcetris™ Order Form
• Alimta® Order Form
• Avastin® Order Form & Information
• Caelyx® Order Form & Information
• Cisplatin® Order Form
• Eloxatin® Order Form & Information
• Erbitux® Order Form & Information
• Gemzar™ Order Form & Information
• Havalen® Order Form
• Herceptin® Order Form & Information
• Jevtana® Order Form
• Kadcyla® Order Form & Information
• Keytruda® Order Form
• Kyprolis ® Order Form
• Opdivo® Order Form
• Perjeta ® Order Form & Information
• Rituxan® Order Form & Information
• Taxotere® Order Form
• Torisel® Order Form & Information
• Treanda® Order Form
• Vectibix® Order Form & Information
• Velcade® Order Form
• Velcade® Maintenance Order Form
• Venofer® Order Form 
• Zometa® Order Form
  

Physician – Frequently Asked Questions

Q: What if a patient is also receiving medication(s) in the public healthcare system?
A: There may be circumstances where patients are also receiving other “funded” intravenous medication from their treating oncologist, in the public system. In such cases the treatments must be coordinated and scheduled appropriately between Provis and the hospital.

Q: What is your “turnaround” time for a new referral?
A: Although we would prefer a few days to process and contact a new referral, we can intake and treat a patient for a Tuesday infusion if we receive the new referral and MOF before 11am on the Monday prior to the Tuesday infusion day.  In rare circumstances, we can process a new referral before 10:30 am on the day of the infusion, depending on the availability of the medication.   At Provis we try and be as flexible as possible.

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 oncologist 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 oncologist 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. Registered oncology nurses, specialized in chemotherapy infusion, administer medications. Our staff has an average of ten years in-hospital oncology nursing experience. Emergency procedures and 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 oncologist 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 oncologist. 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.