Hepatitis C Enrollment Form
354 Folly Road Building # 1
Charleston, SC 29412
PH: (843) 501-9500
FAX: (843) 414-7453
Date: _____________ Needs by date: ___________________________
Ship to: Patient ___ Office: ___ Other: ________________________________________
Patient Information:
Prescriber Information:
Patient Name: ________________________________________________
Prescriber Name: _________________________________________________________
Address: _____________________________________________________
DEA: __________________________ NPI: _____________________________________
City, State, Zip: ________________________________________________
Group: __________________________________________________________________
Main Phone: __________________________________________________
Address: ________________________________________________________________
Alternate Phone: _______________________________________________ City, State, Zip: ___________________________________________________________
Social Security Number: __________________________________ _______
Phone: ________________________ Fax: _____________________________________
Date of Birth: ______________________ Male: ___ Female: ___
Contact Person: __________________________________________________________
INSURANCE INFORMATION: PLEASE FAX A COPY OF PRESCRIPTION CARD AND MEDICAL CARD (FRONT AND BACK)
Clinical Information: Please attach clinical notes/labs for prior authorization process
Diagnosis: ___ 070.54 Chronic Hepatitis C ___ 070.51 Acute Hepatitis C ___ 050.5 Liver Transplant ___ 042 HIV ___ Other: ___________________________________
Fibrosis Stage: ______________________ HCV-RNA: ______________ (IU/ML) and/or log10 value _________________
ICD-10 Code & Description: ________________________________________________________ The Child-Pugh Grade is: ___________________________________
Patient Evaluation
Height: __________ Weight: _________ Allergies: __________________________ Is the readiness to treat form filled out and signed by the patient: Y N
HCV Genotype: _____ 1a _____ 1b _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 AND _____ No Cirrhosis _____ Compensated Cirrhosis _____ Uncompensated Cirrhosis
Is patient _____ Naïve _____ Partial Responder _____ Non-Responder _____ Relapsed
List dates of therapy and outcomes____________________________________________ Product Name: ________________________________________
Is patient currently on Hepatitis C Virus (HCV) therapy? _____ Yes _____ No
If yes, Therapy start date: _______________________________ Product Names: ____________________________________________________________
Prescription Information:
Medication
Strength/Formulation
Directions
90mg ledipasvir/
400mg sofosbuvir
Take one tablet daily
Duration:
□ 8 weeks □ 12 weeks □ 24 weeks □ Other: ______________
Olysio ™
150 mg Capsule
Take one (150mg) capsule once daily with food
Sovaldi ™
400 mg tablet
Take 1 (400mg) tablet once daily
Duration: □ 12 weeks □ 24 weeks □ Other: __________
Harvoni ®
Pegasys ®
PEGIntron ®
Ribavirin
□ 180 mcg/1 ml vial
□ 180 mcg/0.5 ml prefilled Syringe kit of 4
□ 180 mcg/0.5 ml Proclick™ Autoinjector kit
□ 135 mcg/0.5 ml Proclick™ Autoinjector kit
□ Vial
□ REDIPEN ®
□ 50 mcg
□ 80 mcg
□ 120 mcg
□ 150 mcg
□ Inject 180 mcg subcutaneously weekly
□ Inject 135 mcg subcutaneously weekly
□ Other: ______________________________________
□ 200 mg tablet
□ 200 mg capsule
Riba-pak ®
□ 600 mg/day
□ 800 mg/day
□ 1000 mg/day
□ 1200 mg/day
Viekira Pak ™
□ Pak contains:
Ombitasvir, paritaprevir, ritonavir (pink tablets):
12.5/75/50 mg
Dasabuvir (beige tablets): 250 mg
By signing this form and utilizing our services, you are
authorizing Dottie’s Pharmacy and its employees to serve
as your prior authorization designated agent in dealing
with medical and prescription insurance companies.
Inject subcutaneously weekly:
□ 50 mcg □ 80 mcg □ 120 mcg
□ 150 mcg □ Other: ___________________________
Take _____ tabs/caps QAM and ______ tabs/caps QPM
with food
□ Other: ______________________________________
□ Take 600mg tab PO QAM and 600mg tab PO QPM =
1200mg/day (600-600)
□ Take 600 mg tab PO QAM and 400 mg PO QPM =
1000mg/day (600-400)
□ Take 400 mg tab PO QAM and 400mg PO QPM =
800mg/day (400-400)
□ Take 200mg tab PO QAM and 400 mg PO QPM =
600 mg/day (200-400)
□ Take two ombitasvir, paritaprevir, ritonavir (pink) tablets
once daily AM and one dasabuvir (beige) tablet twice daily AM
and PM with a meal
□ Other: ___________________________________________
Duration: □ 12 weeks □ 24 weeks □ Other: ________________
Quantity
Dispense:
□ 28- day
□ Other: __________
Refills: ____________
□ 1 month
□ Other: __________
Refills: ____________
□ 1 month
□ Other: ________
Refills: __________
□ 1 month
□ 3 months
□ Other: ___________
Refills: ____________
□ Qty: __________
Refills: __________
□ Qty: ____________
Refills: ____________
□ Qty: ____________
Refills: ____________
□ 28- day supply
□ Other: ___________
Refills:_____________
Prescriber
Signature: __________________________________________________________ Date: ___________________