HIV ENROLLMENT FORM

HIV ENROLLMENT FORM
Form Name
E-Prescribing is encouraged for quicker turnaround time for our patients.

See our e-prescribe information below!
PATIENT INFORMATION
Patient Name:*
Date of Birth:*

MonthDayYear
Date
Gender:

MaleFemalePrefer Not to SayOther
Address

Address

Street Address Line 2

CityState

Zip
Phone Number:*
Alt. Phone Number:
Allergies:*
If no known drug allergies, please put N/A
Language:
Height:
Weight:
SSN:
Delivery Options:

Patient’s HomePrescriber OfficeAlternative Address:
Alt. Address

Street Address

Street Address Line 2

CityState

Zip Code
PRESCRIBER INFORMATION
Prescriber :*
Provider PIN:*
Please provide your verification PIN. For those new to our pharmacy, please put 11111 and we'll reach out to you to set up a PIN.
NPI:*
DEA:*
Phone Number:*
Fax Number:
Practice Name:
Office Contact:
Practice Address

Street Address

Street Address Line 2

CityState

Zip Code
CLINICAL INFORMATION
Please upload all relevant and available chart notes including lab results:

Cancelof
Diagnosis:
ICD-10:
Serum Creatinine:
CD4 Count:
Viral Load:
Date of labs:

MonthDayYear
Date
PrEP:
PRESCRIPTION INFORMATION

Please select a medication first, then complete and required Dose, Directions, Quantity and Refills
Medication

Aptivus®Atripla®Biktarvy®Combivir®Complera®Descovy®Edurant®Emtriva®Epivir®Epzicom®Evotaz®Fuzeon®Genvoya®Intelence®Invirase®Isentress®Juluca®Kaletra®Lexiva®Norvir®Odefsey®Prezcobix®Prezista®Reyataz®Selzentry®Stribild®Sustiva®Tivicay®Triumeq®Trizivir®Truvada®Valcyte®Viramune®Viread®Vitekta®Ziagen®
Medication 1
Refills:
Strength/Directions (SIG):
Qty:
Medication 2
Refills:
Strength/Directions (SIG):
Qty:
Medication 3
Refills:
Strength/Directions (SIG):
Qty:
Medication 4
Refills:
Strength/Directions (SIG):
Qty:
Medication 5
Refills:
Strength/Directions (SIG):
Qty:
Medication 5
Refills:
Strength/Directions (SIG):
Qty:
Comments
PRESCRIBER SIGNATURE

Please indicate substitution preferences, 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

Product substitution permittedDispense as WrittenTherapeutic substitution permitted
Prescriber Signature

Clear
Date

MonthDayYear
Date
CONFIDENTIALITY NOTICE: This form and its contents may contain private and confidential information that is intended for the individual or entity to which it is addressed. Any transmission of this form may contain information that is exempt from disclosure under laws including but not limited to the Health Insurance Portability and Accountability Act (HIPAA Unless explicitly stated, you are strictly prohibited from disseminating, copying or distributing any material contained within. Violators will be prosecuted to the fullest extent of the law. If you received this communication in error, please notify us immediately and destroy this form and its contents.
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