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Hepatitis C Referral Form

This referral form is provided in order to best serve our patients and prescribers. Patients may choose any pharmacy of their choice.

Complete patient demographics below or otherwise provide the information requested along with this referral form. Also needed: 1) Patient insurance information (front and back of card) 2) History and physical, chart notes, laboratory results and other diagnostic tests needed to support the use of this medication, including Genotyping, viral counts, liver disease staging, as well as patient’s medication history related to their current diagnosis/problem.

Prescription Information


Regarding oral medication prescriptions: MedRx will transfer to the patient’s retail Pharmacy if we are unable to provide this medication due to insurance payer requirements.

IMPORTANT NOTICE: This form my contain confidential and privileged information and is only intended only for the person named herein. If you are not the named addressee, do not disseminate, distribute or copy this form or any of its contents. Please notify the sender immediately if you have received this document by mistake, then destroy this form.