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Provider Information

POLAR Healthcare Pro Corp™ provides mobile and ambulatory vascular access services in Houston and surrounding areas, specializing in PICC line insertion and Midline Catheter Placement for adult patients. To prevent delays, please send the items below at the time of referral so our team can schedule quickly and safely.

Quick Check List - Vascular Access Service

  • Vascular Access Order / Referral Form
  • Flushing Protocol Order Form
  • Dressing Change / Catheter Care Order Form
  • History & Physical
  • Recent Labs

What we need from your office:

Required for scheduling (Send via HIPAA Secure FAX Line)

  1. Vascular Access Order / Referral 
    [CLICK HERE] FILLABLE ONLINE REFFERAL FORM HERE

    • Specify PICC (with 3CG-TCS for Line Confirmation) or Midline

    • Indication (e.g., IV antibiotics, difficult access, long-term therapy)

    • Any special instructions (lumens, side preference if medically required)

    • Urgency: POLAR | STAT (<4 Hours), Urgent, Routine

  1. Flushing Protocol Order Form 

    Purpose: Authorizes POLAR to perform catheter flushing to maintain patency and prevent occlusion.

    Must specify:

    • Device type:

      • ☐ PICC or Midline

    • Flush solution:

      • ☐ Normal Saline

      • ☐ Heparin (if applicable)

    • Volume and frequency:

      • Example: 10 mL NS before and after use

    • Frequency:

      • ☐ After medication administration

      • ☐ Weekly maintenance

      • ☐ PRN per protocol

  2. Dressing Change / Catheter Care Order Form

    (Required for ongoing line care)

    Purpose: Authorizes POLAR to provide sterile dressing changes and catheter site care if Home Health Services is covering care or in-patient facility does not perform dressing changes.

    Must specify

    • Device type:

      • ☐ PICC or Midline

    • Dressing change frequency:

      • ☐ Weekly

      • ☐ PRN (loose, soiled, compromised)

    • Securement method:

      • ☐ StatLock / Securement device

      • ☐ Per facility protocol

    • Antiseptic:

      • ☐ CHG (if tolerated)

      • ☐ Alternative (specify if CHG allergy)

     

  3. Recent Labs (preferred)
    Please send recent labs (ideally within 72 hours) when available:

      • CBC (for platelet assessment)

      • BMP (for baseline clinical review)

    • PT/INR (bleeding risk assessment, when applicable)

  1. History & Physical / Most recent clinical note

    • Diagnosis/indication and current status

    • Any relevant vascular access history/complications

    • Allergies (especially CHG, adhesives, lidocaine, latex)

Strongly recommended (Prevents Same-Day Cancellations)

  • Medication Profile / Therapy Plan (OPAT, Chemo, IVIG, TPN)

    • Drug name(s), concentration, frequency, and anticipated duration

    • Vesicant/irritant status (if known)

    • Therapy Plan 

  • Allergies (especially CHG, adhesives, lidocaine, latex)

  • Recent imaging (if available) that impacts access planning (prior DVT, central stenosis, etc.)