HEPATITIS C REFERRAL FORM

HEPATITIS C REFERRAL FORM		Today's Date
314 E 204th St., Bronx, NY 10467		April 29, 2024
Phone: 718-882-5614 Fax: 718-882-6365		New Patient Current Patient

Patient Name	SS#	Date Of Birth	Height	Weight	Gender
					Male Female
Street Address		Apartment #	City	State	Zip

Evening Telephone	Cellphone	Text Messages Allowed	Email Address
		Yes No
Caregiver Name		Ship To Patient At
		Home Work OR Patient will pick up at Physical Office Pharmacy
Allergies			Comorbiditie

Current Medications (If necessary, please fax a complete list)

Previously Treated	If yes, what drugs?	Interferon	# of Weeks	Treatment Response
Yes No		Yes No		Relapsed	Partial Response	Null Response
ICD-10 CODE	B18.2 HCV (Chronic)	Genotype	Subtype	Liver Biospsy	Date	Results
				Yes No
Other Lab Results ALT	Date	AST	Date	Hgb	Date	HCV RNA	Date

Insured's Name		Relation to Patient	Eligible for Medicare	If yes, Medicare #
			Yes No
Prescription Card	If Yes, Carrier	Telephone	Fax Number	Policy/Group #
Yes No
BIN #	PCN #	RXID #	RX Group #

Prescriber's Name			Office Contact

Street Address	Suite #	City	State	Zip

Telephone	Fax Number	Email Address

License #		NPI #	UPIN #	DEA #

Prescription PLEASE ATTACH COPIES OF PATIENT'S INSURANCE CARDS

ZEPATIER	Grazoprevir 100mg/ Elbasvir 50mg tab GT 1 & 4 ONLY
NS5A test for GT1a patients
Yes No	12 wks 16 wks
SIG: Take one tablet by mouth daily Refill with RIBAVIRIN ?	QTY: 28	Refill
Yes No	If No: SeeRIBAVIRINbox for dosages

DAKLINZA	Genotypes 1 & 3 ONLY
30 mg with 400 mg SOVALDI	QTY: 28	Refills x
60 mg with 400 mg SOVALDI	QTY: 28	Refills x
SIG: take 1 tablet each daily

VIEKIRA PAK	28 Day Supply	Refills
Ombitasvir/Paritaprevir/Ritonavir 12.5mg/75 mg/50 mg tabs (pink) Dasabuvir 250 mg tab (beige)
Directions:Take 2 pink tabs PO once daily (AM) with food and one beige tab PO twice daily (AM and PM) with food

HARVONI	Ledipasvir 90 mg / Sofosbuvir 400 mg
SIG: Take 1 tablet by mouth daily
QTY: 28	Refills x

TECHNIVIE	Genotype 4 ONLY
Paritaprevir/Ritonavir (75/50mg) and Ombitasvir (12.5mg)
SIG: two tablets QAM with meal and withRIBAVIRIN

RIBAVIRIN	RIBAPAK	MODERIBA
600mg/day 200mg QAM 400mg QPM
800mg/day 400mg QAM 400mg QPM
1000mg/day 600mg QAM 400mg QPM
1200mg/day 600mg QAM 600mg QPM
200mg
Other:
QTY 28 days	Refill x

SUPPORTIVE THERAPIES
Procrit	Epogen	Neulasta
Aranesp	Neupogen

OLYSIO (Simeprevir)
50mg capsule

SOVALDI Sofosbuvir 400mg tablet

Take 1 tablet by mouth daily for:
800mg/day 400mg QAM 400mg QPM	12 weeks with Ribavirin (Genotype 2)	24 weeks with Ribavirin (Genotype 3)
Other Combination

PEGINTRON REDIPEN	PEGASYS


Quantity: 28 days

HEPATITIS B ORAL THERAPIES
Baraclude	0.5mg	1.0mg
Epivir HBV 100mg	Hepsara 10mg	Tyzeka 600mg

1 Tablet po QD	Quantity
	1 Month	3 Month

Prescriber's SignatureDate: April 29, 2024

IMPORTANT NOTICE: This form is intentded to be delivered only to the named addressee. It contains material that is confidential, privilaeged, proprietary or exempt from disclosure under applicable law. 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 in error and then destroy this document immediately.

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