Home Infusion referrals

In an effort to serve our patients more effectively, on 4/13/2026 the HME Specialists office at 611 Osuna Rd NE Albuquerque, NM 87113 will be moving to 3901 Masthead NE, Albuquerque, NM 87109. All contact phone numbers, hours of operation and services being provided will be maintained.

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Respiratory
- Home Oxygen Therapy
- Sleep Therapy
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Home Infusion Therapy
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Re-order CPAP Supplies

Please complete information below

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Patient Name:*

Drug:*

Date of Birth*

MM slash DD slash YYYY

Dose:*

Address:*

Frequency:*

City:*

End of Therapy Date:*

State:*

Zip:*

Diagnosis:*

Diagnosis Code:*

Phone*

Alternate Phone:

Following MD:*

Caregiver:*

Phone*

Phone

(if different)

Pt. Height*

Pt. Weight*

Allergies*

Flushing Orders:

Normal Saline 0.9% up to 10ml IV per SAS(H) protocol. 10ml IV after lab draw and as needed

Heparin (10 U/ml if pediatric, l00U/mL if adult), 5ml IV per SASH protocol.

Other:

Labs: Every Monday (Only draw labs specific to IV therapy)

All Antibiotic Therapies - CMP, CBC w/ diff, CRP, ESR

If on Vancomycin - CMP, CBC w/ diff, CRP, ESR, CK, trough weekly/PRN

If on Daptomycin or Gentamycin - CMP, CBC w/ diff, CRP, ESR, CK

If on TPN - CMP, CBC w/ diff, ESR, CRP, Mag, Phos, Triglycerides

Skilled Nursing:

Skilled nursing has been arranged with:

HIT Specialists to arrange Skilled Nursing.

Nursing to instruct patient / caregiver in administration of therapy, troubleshooting, catheter management and signs/symptoms of complications related to therapy and assess response to therapy.

Additional Orders:

Convert to catheter care maintenance if infusion therapy is complete and line access needs to be maintained. Flush each lumen daily with Normal Saline± Heparin.

DC PICC at conclusion of prescribed therapy.

Other:

Prescriber Signature:

Date:

Prescriber Name:

NPI:

Phone:

Fax:

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