Referral Forms

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Synagis Referral Forms

Independence Blue Cross Synagis Forms:
Printed Form / Fillable Form

IBC Administrators Synagis Forms:
Printed Form / Fillable Form

AmeriHealth Synagis Forms:
Printed Form / Fillable Form

AmeriHealth Administrators Synagis Forms:
Printed Form / Fillable Form

Bluelink TPA Synagis Forms:
Printed Form / Fillable Form

PerformSpecialty® is everything you want from a specialty pharmacy, done better. That’s because we are more than specialty pharmacy; we are an organization dedicated to managing the complete care of our patients. Our founders have more than two decades of personalized care experience — the kind of hands-on attention patients need — and we’ve built our company on those principles. With PerformSpecialty, you won’t just get your medication: you’ll get better care.

855-287-7888
Monday through Friday
8:00 a.m. to 7:00 p.m. (EST)
Saturday
8:00 a.m. to 12:00 p.m. (EST)

855-287-7888
Monday through Friday
8:00 a.m. to 7:00 p.m. (EST)
Saturday
8:00 a.m. to 12:00 p.m. (EST)

855-287-7888
Monday through Friday
8:00 a.m. to 7:00 p.m. (EST)
Saturday
8:00 a.m. to 12:00 p.m. (EST)