Hepatitis C Enrollment Form

Hepatitis C Enrollment Form
FaxReferral
Referral
877-552-2907
Phone: 888-345-1678
Fax
To:To:
877-552-2907
Phone: 888-345-1678
Email
Referral
To: To:
[email protected]
E-mail
Referral
[email protected]
6 Simple steps to submitting a referral
11 PATIENT INFORMATION
22 PRESCRIBER INFORMATION
Prescriber’s Name:
(Complete the following or include demographic sheet)
Patient Name:
State License #:
Address:
DEA #:
City, State, Zip:
Group or Hospital:
Primary Phone:
Home
Alternate Phone:
Home
DOB:
Gender:
Cell
Cell
Male
Work
Address:
Work
City, State Zip:
Female
E-mail:
Last Four of SS #:
NPI #:
Phone:
Fax:
Contact Person:
Phone:
Primary Language:
3
INSURANCE INFORMATION Please fax copy of prescription and insurance cards with this form, if available (front and back)
4
DIAGNOSIS AND CLINICAL INFORMATION
Diagnosis (ICD-9 or ICD-10):
070.54 Chronic Hepatitis C
Needs by Date:__________ Ship to:
070.51 Acute Hepatitis C
Patient
050.5 Liver Transplant
Office
042 HIV
Other:___________
Other:_____________
ICD-10 Code & Description:_____________________________________________________________________________________________________
Patient Evaluation:
Height: ____________________________in/cm
HCV Genotype:
Is patient:
1a
Naïve
1b
1
2
Partial Responder
3
Weight: ____________________________kg/lbs
4
5
Non-Responder
Last Date of Therapy:
Allergies:____________________________
6
Relapser
Product Names:
Is patient currently on Hepatitis C Virus (HCV) therapy?
Yes
If Yes, Therapy Start Date:
No
Product Names:________________________________________________________________
Specialty Pharmacy to coordinate injection training/home health nurse visit as necessary.
Yes
No
PRESCRIPTION INFORMATION
5
MEDICATION
PEGASYS
PEGINTRON
DOSE/STRENGTH
180 ug/0.5 ml ProClick Autoinjector
Other
REDIPEN®
120 mcg
150 mcg
Other
RIBAVIRIN
200mg tablets
RIBA-PAK
600/600mg
400/400mg
200 mg caps
VICTRELIS™
(boceprevir)
200mg capsules
600/400mg
200/400mg
DIRECTIONS
QUANTITY
REFILLS
Inject 180ug subcutaneously once a week as directed
Inject __ mcg subcutaneously weekly
Other:
Take __ tabs/caps oral qam and __ tabs/caps qpm to equal a total of ____ mg/day
.
Take ___ mg oral qam and ___ qpm to equal a total of ___ mg/day
Take 800 mg orally three times daily every 7-9 hours with food. Begin after week
4 of pegylated interferon therapy.
28 day
supply
Sovaldi
(sofosbuvir)
400 mg tabs
Take one 400mg tablet orally once a day
28 day
supply
Olysio
(simeprevir)
150 mg capsule
Take one 150mg capsule orally once a day
28 day
supply
Maximum12wks
Take orally once daily.
28 day
supply
Maximum 8wks
Maximum12wks
Sofosbuvir/
ledipasvir
Fixed-dose combination tablet of 90
mg of ledipasvir/400 mg of sofosbuvir
Patient is interested in patient support programs
6
STAMP SIGNATURE NOT ALLOWED
X
DISPENSE AS WRITTEN
Ancillary supplies and kits provided as needed for administration
X
(Date)
PRODUCT SUBSTITUTION PERMITTED
(Date)
IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone
other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or
retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Hepatitis C 022514