Order Form

YERVOY® (ipilimumab)

YERVOY® (ipilimumab) is a prescription medicine administered by intravenous infusion used in adults and children 12 years of age and older to treat melanoma that has spread or cannot be removed by surgery as well as preventing melanoma from coming back after it and lymph nodes that contain cancer have been removed by surgery.

For more information, please refer to the YERVOY® website, prescribing information, and/or medication guide.

Note: Please speak with your healthcare provider for more information if you think this therapy might be right for you.

How do I make a referral or transition my treatment to Infusion Associates?

1. Ask your healthcare provider to fax us a completed order form for your medication, clinical notes, demographics and your insurance card to (833) 996-4888.

2. Providers can find order forms on our medications page.

3. One of our intake specialists will contact your healthcare provider to confirm receipt of your referral.

4. We will then verify benefits, obtain any required prior authorizations, and contact you to schedule an appointment.