HEPATITIS C ENROLLMENT FORM

Form Name

E-Prescribing is encourgaed for quicker turnaround time for our patients.

See our e-prescribe information below!

Patient Information

Please attach a copy of the patients insurance card

Browse Files

Patient Name*

First NameLast Name

Date of Birth:*

MonthDayYear

Gender

MaleFemale

Address

Street Address Line 2

CityState

Zip

Cell Phone Number:

Alternate Phone Number:

Language:

Allergies (Required):

If No Known Drug Allergies, please put N/A

Height:

Weight:

SSN:

Product Shipping Options:

Patient’s HomePrescriber OfficeAlternative Address:

Alternative Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Prescriber Information

Prescriber :*

Phone Number:*

NPI:*

DEA:

Practice Name:

Office Contact:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fax Number:

Clinical Information

Please provide all relevant available chart notes and lab results

Browse Files

ICD -10/ Diagnosis :

Patient type:

naïverelapsepartial respondernull responder

Co-Infections :

NoneHIVHepatitis B

Prior Failed Therapy:

Is there cirrhosis?

YesNo

If yes, is it:

compensateddecompensated

Fibrosis Stage

Child Pugh Score (if cirrhosis)

Activity

eGFR: blanks mL/min/1.73m2

Genotype/Subtype:

Baseline viral load (IU/mL): blanks
Baseline viral load (Log UI/mL: blanks

Is the patient interferon intolerant?

YesNo

Fibroscan™ (kPa):

FibroSURE®:

Is the patient awaiting liver transplant for hepatocellular carcinoma?

YesNo

NS5A Test results:

resistantnon-resistant

Hep B panel:

HBsAgHBcAbHBsAb

Prescription Information

After selecting the medication type, please complete Rx info

Medication

Mavyret Rx Info
Dose: 100 mg / 40 mg
Directions: Take 3 tablets by mouth once daily with food for Enter number of weeks weeks.
Quantity: 84
Refills: Enter refills

Zepatier Rx Info
Dose: 50 mg / 100 mg
Directions: Take 1 tablets by mouth once daily with or without food for Enter number of weeks weeks.
Quantity: 28
Refills: Enter number of refills

Epclusa Rx Info
Dose: 400 mg / 100 mg
Directions: Take 1 tablets by mouth once daily with or without food for Enter number of weeks weeks.
Quantity: 28
Refills: Enter number of refills

Harvoni Rx Info
Dose: 90 mg / 400 mg
Directions: Take 1 tablets by mouth once daily with or without food for Enter number of weeks weeks.
Quantity: 28
Refills: blank

Vosevi Rx Info
Dose: 400/100/100 mg
Directions: Take 1 tablet by mouth once daily with food for Enter number of weeks weeks.
Quantity: 28
Refills: Enter number of refills

Sovaldi Rx Info
Dose: 400 mg
Directions: Take 1 tablet by mouth once daily with or without food for Enter number of weeks weeks.
Quantity: 28
Refills: Enter number of refills

Daklinza Dose:

Daklinza Rx Info
Directions: Take 1 tablet by mouth once daily with or without food for Enter number of weeks weeks.
*30 mg dose is utilized when given in combination with strong CYP3A inhibitors.
90 mg dose is to be administered when given in combination with moderate inducers of CYP3A.
Quantity: 28
Refills: Enter number of refills

Olysio® Rx Info
Dose: 150 mg
Directions: Take 1 capsule by mouth once daily with or without food for Enter number of weeks weeks.
Quantity: 28
Refills: Enter number of refills

For Olysio® order, is the Q80K polymorphism present?

YesNo

Viekira XR (ombitasvir, paritaprevir, ritonavir, dasaburvir) Rx Info
Dose: 2.33/50/33.33/200 mg
Directions: Take 3 tablets by mouth once daily with food for Enter number of weeks weeks.
Quantity: 84
Refills: Enter number of refills

Ribavirin 200 mg:

CapsuleTablet

Ribavirin 200 mg: Directions

Take 600 mg by mouth in the morning and 400 mg by mouth in the evening with food - (for patients ≤ 165 lbs )Take 600 mg by mouth in the morning and 600 mg by mouth in the evening with food - (for patients ≥ 165 lbs )

Ribavirin 200 mg: Quantity

140168

Ribavarin 200 mg: Refills

Prescriber Signature (Please sign and date below)

Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms, the receipt and submission of patient lab values and other patient data including pursuing available copay and financial assistance on behalf of my patients. If this pharmacy determines that it is unable to fulfill this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.

Substitution preferences

Generic substitution permittedTherapeutic substitution permittedDispense as Written

Signature*

Date

MonthDayYear

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