Download Hepatitis C Referral Form

Ship to: Patient Physician 1st order only Physician all orders  Other___________________
Need Nurse Need Training
 Enroll patient in advanced case management services (see your AcariaHealth representative for details)
Phone: 800-511-5144
Fax: 877-541-1503
Hepatitis C Referral Form
Patient Name: ___________________________________________________
Address:_______________________________________________________
City:
State: _________ Zip: _____________
Home Phone: (__________) ______________ - _______________________
Work Phone: (__________) ______________ - _______________________
Cell Phone: (__________) ______________ - _______________________
Patient Soc. Sec #:____________________Allergies:_____________________
Date of Birth:_____/_____/_____Sex: Male Female Weight:___ lbs ___ kg
Physician Name:_________________________________________________
Patient ethnicity:______________________________________________________
 See attached demographic sheet Height:______
BSA______ m²
Physician’s Fax: (__________) ____________ - _______________________
State Lic # _____________________ DEA # __________________________
NPI # _________________________ Specialty: ________________________
Practice Name/Hospital: ___________________________________________
Address:_______________________________________________________
City: _______________________________State: _______Zip:____________
Physician’s Ph: (__________) ____________ - ________________________
Nurse/Key Office Contact: __________________________________________
Primary Insurance:___________________
INSURANCE INFORMATION (Please Attach Copies of front and back of cards)
Secondary Insurance:________________
Rx Card (PBM):_____________________
Cardholder First Name: _______________
City:______________State:___________
City:______________State:___________
PBM BIN: _________________________
Last Name: ________________________
Plan #: ___________________________
Plan #: ___________________________
City:______________State:___________
Employer: _________________________
Group #: __________________________
Group #: __________________________
Group #: __________________________
ID #: _____________________________
Phone: (______) ________-__________
Phone: (______) ________-__________
Phone: (______) ________-__________
Group #: __________________________
DIAGNOSTIC INFORMATION Please Fax Medication Profile to AcariaHealth
070.54 Hepatitis C (Chronic) Other ICD 9 __________ Genotype: 1 1a 1b 2 2a 2b 3 3a 3b 4 4a 4b 5  6 Other______________________
Viral Load: __________________________ Treatment Naïve
Previous treatment: ________________________Non-Responder Partial Responder Responder/Relapser
Duration of prior treatment: From ______________ To _____________ Total of _________ Weeks Co-infected with: HIV HBV N/A Cirrhosis: Compensated De-compensated
History of liver biopsy?: Yes No N/A Fibrosis present?: Yes No N/A History of liver test?: Yes No N/A Fibro score: ______ N/A IL28B genotype ______
Transplant Patient  Yes No
Interferon intolerant  Yes No
Q80K polymorphism present?: Yes No N/A
 Labs: to be performed prior to therapy and monitored during treatment at appropriate intervals (particularly pregnancy test for woman of childbearing potential)
ALT ____ AST_____ Hgb____ Plt_____ Serum creatinine___________date of last laboratory draw ___________
 Other medications patient is currently taking (including OTC medications): _______________________________________________________________________________
 Other disease states: Depression Anxiety Diabetes Other _________________________________________________________________________________________
PRESCRIPTION INFORMATION
□
Sovaldi®
□
(sofosbuvir) 400mg
1 tablet PO once daily
Supply: 1 mo
Refill:
Supply: 1 mo
Refill:
□ Olysio® (simeprevir) 150mg
1 capsule PO once daily
1 tablet PO once daily
Supply: 1 mo
□ OK to substitute Ribapak/Moderiba with Ribavirin if non-formulary
□
□ Harvoni® (ledipasvir / sofosbuvir) 90mg/400mg
Refill:______
RIBAPAK®
□ MODERIBA® □ RIBAVIRIN 200mg
□ 400mg PO QAM; 200mg PO QPM Supply: 1 mo Refill:
□ 400mg PO QAM; 400mg PO QPM Supply: 1 mo Refill:
□ 600mg PO QAM; 400mg PO QPM Supply: 1 mo Refill:
□ 600mg PO QAM; 600mg PO QPM Supply: 1 mo Refill:
□ Other:_______________________ Supply: 1 mo Refill:______
Other*__________________________________________
____________________________ Supply: 1 mo Refill:
ks
I authorize any division of AcariaHealth to enroll me in a manufacturer-assisted patient support program, corresponding with my prescribed therapy for purposes of receiving additional services such as, but not limited to: injection training. I
further authorize the release to the corresponding manufacturer the minimum necessary information about my health condition a nd prescriptions to: coordinate the delivery of products and services available through the patient assistance
program , aggregate de-identified data for market analysis, and provide educational information regarding therapies. I understand that I may revoke this authorization at anytime in writing by sending a letter to AcariaHealth 2301 Caroline St.,
Houston, TX77004. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment 
fromDAW
the pharmacy.
(Dispense as Written)
A copy of this authorization will be utilized with the same effectiveness as the original.
______________________________________________ ______________________
Patient Signature (required for participation)
Date
Physician’s Signature: ____________________________________
Date____/_____/____
Physician’s Signature: ____________________________________ DAW (Dispense as Written)
Date____/_____/____
Prescriber certifies that this referral form contains an original signature and is signed by the treating physician
IMPORTANT NOTICE: This message may contain privileged and confidential information and is intended only for the individual named. If you are not the named addressee, you should not disseminate, distribute or
copy this fax. Please notify the sender immediately if you have received this document by mistake, then destroy this document. Please direct all verification or notification to AcariaHealth or any of its subsidiaries
using the contact information provided on this coversheet.
Rev.: 10/10/2014