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.

Date Medication Needed:

Ship to:

Patient

Prescriber

Other

Self injection teaching needed

Prescriber’s office will teach patient self administration

Patient first name:

Patient last name:

Date of birth:

height:

weight:

Address:

Allergies/Intolerances:

Phone number(s):

No known allergies:

Treatment Diagnosis/Problem(s):

Failed medication with reasons:

Prescriber name:

Contact person:

Office Address:

Phone number:

Fax number:

NPI number:

Prescription Information

4 weeks supply for

months

4 weeks supply for

months

Other

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.

Dispense supplies necessary for administration and hazardous waste disposal.

Date:

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.