Hepatitis C Enrollment Form
Form will be automatically sent to Sunray Specialty Pharmacy for processing. Please send an electronic prescription along with this form to avoid delays.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Gender
*
Please Select
Male
Female
Non-Binary
Prefer Not To Disclose
Patient's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Height
*
Patient's Weight
*
Allergies to Medications
*
Concomitant Medications
*
Prescriber
*
Which medication is being prescribed for the patient?
*
Epclusa (or authorized generic)
Mavyret
Vosevi
Other
Did the patient already begin therapy?
*
Yes
No
When did the patient begin therapy?
*
-
Month
-
Day
Year
Date
Is medication to be delivered to the patient's address or the office?
*
Please Select
Patient
Office
When would you like the medication delivered to the office?
*
-
Month
-
Day
Year
Date
How long will the patient take the medication?
*
8 weeks
12 weeks
16 weeks
Other
Has the patient been treated for hepatitis C in the past?
*
Yes
No
What medication(s) did the patient take previously?
Peg-interferon
Harvoni
Epclusa
Mavyret
Unsure
Other
How long did the patient take this medication? (if multiple medications, please specify for each)
What was the result of the previous treatment(s)?
Treatment complete and SVR-12 achieved
Treatment complete but SVR-12 was not achieved
Treatment incomplete due to adherence
Other
What is the HCV genotype?
*
1a
1b
2
3
4
5
6
Unknown
What is the HCV viral load?
*
What is the patient's FIB-4 score?
*
Does the patient have HIV?
*
Yes
No
Does the patient have hepatitis B?
*
Yes
No
Would you like the medication to be delivered to the office?
Please Select
Yes
No, deliver directly to patient
What is the address of the office?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When will the patient be returning to start therapy?
-
Month
-
Day
Year
Date
Please upload the following labs and documentation or fax to (215)471-4001: HCV RNA, FIB-4 score (documented in notes is acceptable), genotype (if required), RAS testing (if required), and HIV screening. If writing for non-preferred agent (Vosevi), please include documentation of past treatment(s). Prior authorization requests cannot be processed without labs and documentation.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: