skip to Main Content
REFERRAL FORM FOR COVID TREATMENT WITH REGEN-COV

REFERRAL FORM FOR COVID TREATMENT WITH REGEN-COV

Dear Provider,

We are excited to announce that Arizona Clinical Trials/Arizona Covid Care will be providing REGEN-COV™ (casirivimab and imdevimab) for treatment and prevention of COVID-19. REGEN-COV™ has received emergency use authorization by the FDA for the following indications:

Treatment:

REGEN-COV is authorized for the treatment of mild to moderate COVID 19 in adults and pediatric patients (12 years of age and older weighing at least 40 kg) with positive results of SARS-CoV-2 testing, and who are at high risk for progression to severe COVID-19, including hospitalization or death.

*Patients should be treated within 10 days of symptom onset and as soon as possible after positive COVID test.

Prophylaxis

For post-exposure prophylaxis of COVID-19 in individuals (12 years of age and older weighing at least 40 kg) who are at a high-risk for progression to severe COVID-19, including hospitalization or death*

*See attached form or go to www.regencov.com for specific inclusion and exclusion criteria.

Next Steps for Patient Referral:

Please click here to access the form and include a copy of the patient’s insurance, positive COVID-19 test (if applicable), office visit notes. We will reach out to the patient within 24 hours for evaluation and treatment as indicated. Our providers have treated over 1,000 patients for COVID or prophylaxis of COVID with monoclonal antibodies since July 2020.

• Fax completed form, test results, and office notes to Arizona Clinical Trials/Arizona Covid Care at 480-686-8875. For more information call 480-360-4000 (Phoenix) or 520-445-4000 (Tucson).

Leave a Reply

Your email address will not be published. Required fields are marked *

Back To Top