Prescription/Pharmacy Intake Form - Walgreens Intake Form ... Initial Viral Load:IU/mL Date of...
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Hepatitis C/HCV Prescription/Pharmacy Intake Form ***Select one of our Central Pharmacy numbers from the drop‐downs below, or type a Retail/Community Pharmacy number in the blank space provided Rx Phone: Provider Representative Rx FAX: Specialty Care Center Patient’s Home Prescriber’s Office Phone Other Patient Name: DOB: Male Female Address: City: State: Zip Code: Phone # (Daytime): Phone # (Evening): E‐mail Address: Insurance Provider (Please include copy of front and back of card): ID #: Policy/Group #: Phone #: Name of Insured: Employer: Relationship to Patient: Self Other: Patient is Eligible for Medicare Prescription Card: Yes No Carrier: Policy/Group #: Patient is Naive Patient is a Null Responder Patient is a Relapser Primary Diagnosis Code: Current Weight: Date: Height (pediatrics): Date: Genotype: ͱa ͱb Ͳ ͳ ʹ ͵ Ͷ Positive for QͰK Polymorphism Initial Viral Load: IU/mL Date of Initial Viral Load: Previous Treatment: No Yes, with Fibrosis Score: Cirrhosis Decompensated Other Health Conditions: Allergies: Concomitant Medications: PATIENT INFORMATION Prescriber’s Name: Practice/Facility Name: Address: Office Contact: City: State: Zip Code: Phone #: Fax: Best Time to Call: State License #: DEA #: NPI#: Medicaid UPIN #: In order for a brand name product to be dispensed, the prescriber must handwrite “Brand Necessary” or “Brand Medically Necessary,” or your state specific required language to prohibit substitution: I certify that the above therapy is medically necessary and that the information above is accurate to the best of my knowledge. Prescriber’s Signature Required: Date: Secondary Signature Optional: Date: Medication Directions/Freq Qty Refills Harvoni® Ͱmg/ʹͰͰmg tablets Olysio® ͱ͵Ͱ mg capsules Sovaldi® ʹͰͰ mg tablets Technivie® Viekira Pak® Moderiba™ Ribasphere® ͲͰͰ mg tablets ͲͰͰ mg capsules Moderiba™ Dose Pack Ribasphere® Ribapak® ͶͰͰmg/day = ͲͰͰ‐ʹͰͰ: ͲͰͰ mg AM/ʹͰͰ mg PM ͰͰ mg/day = ʹͰͰ‐ʹͰͰ: ʹͰͰ mg AM/ʹͰͰ mg PM ͱ,ͰͰͰ mg/day = ͶͰͰ‐ʹͰͰ: ͶͰͰ mg AM/ʹͰͰ mg PM ͱ,ͲͰͰ mg/day = ͶͰͰ‐ͶͰͰ: ͶͰͰ mg AM/ͶͰͰ mg PM Ribavirin ͲͰͰ mg tablets ͲͰͰ mg capsules ͱͰ mcg/ͱ mL vial ͱͳ͵ mcg/Ͱ.͵mL ProClick™ ‐ʹ autoinjectors ͱͰ mcg/Ͱ.͵ mL ProClick™ ‐ʹ autoinjectors CLINICAL ASSESSMENT PRESCRIPTION INFORMATION PRESCRIBER INFORMATION The document(s) accompanying this transmission may contain confidential health information that is legally protected. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party unless permitted or required to do so by law or regulation. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents. ©2016 Walgreen Co. All rights reserved. 30 mg 60 mg Aranesp® Neulasta® Procrit® Granix® Neupogen® Promacta® Daklinza™ ͱͲ.͵/ͷ͵/͵Ͱmg tablets Zepatier™ 50mg/100mg tablets Note: This form is intended for prescriber use only. If faxed, the fax must come from MD office or hospital (should not be faxed by patient). 90 mg Epclusa® ʹͰͰmg/100mg tablets Viekira XR™ ͱͲ.͵/ͷ͵/͵Ͱmg and Ͳ͵Ͱmg tablets 200/8.33/50/33.33mg tablets
Transcript of Prescription/Pharmacy Intake Form - Walgreens Intake Form ... Initial Viral Load:IU/mL Date of...
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Hepatitis C/HCV Prescription/Pharmacy Intake Form
***Select one of our Central Pharmacy numbers from the dropdowns below, or type a Retail/Community Pharmacy number in the blank space provided
Rx Phone: Provider Representative
Rx FAX: Specialty Care Center Patients Home
Prescribers Office
Phone Date Needed Ship to
Other
Patient Name: DOB: Male Female Address:City: State: Zip Code:Phone # (Daytime): Phone # (Evening): Email Address: Insurance Provider (Please include copy of front and back of card): ID #: Policy/Group #: Phone #: Name of Insured: Employer: Relationship to Patient: Self Other: Patient is Eligible for Medicare Prescription Card: Yes No Carrier: Policy/Group #:
Patient is Naive Patient is a Null Responder Patient is a Relapser
Primary Diagnosis Code: Current Weight: Date:
Height (pediatrics): Date:
Genotype: a b Positive for QK Polymorphism
Initial Viral Load: IU/mLDate of Initial Viral Load: Previous Treatment: No
Yes, with Fibrosis Score: Cirrhosis
Decompensated Other Health Conditions:
Allergies:
Concomitant Medications:
PATIENT INFORMATION
Prescribers Name: Practice/Facility Name:Address: Office Contact: City: State: Zip Code:Phone #: Fax: Best Time to Call: State License #: DEA #: NPI#: Medicaid UPIN #: In order for a brand name product to be dispensed, the prescriber must handwrite Brand Necessary or Brand Medically Necessary, or your state specific required language to prohibit substitution: I certify that the above therapy is medically necessary and that the information above is accurate to the best of my knowledge.
Prescribers Signature Required: Date: Secondary Signature Optional: Date:
Medication Directions/Freq Qty Refills
Harvoni mg/mg tablets Olysio mg capsules Sovaldi mg tablets Technivie Viekira Pak
Moderiba Ribasphere mg tablets mg capsules
Moderiba Dose Pack Ribasphere Ribapak mg/day = : mg AM/ mg PM mg/day = : mg AM/ mg PM , mg/day = : mg AM/ mg PM , mg/day = : mg AM/ mg PM
Ribavirin mg tablets mg capsules Pegasys
mcg/. mL prefilled syringe pack mcg/ mL vial mcg/.mL ProClick autoinjectors mcg/. mL ProClick autoinjectors
CLINICAL ASSESSMENT PRESCRIPTION INFORMATION
PRESCRIBER INFORMATION
The document(s) accompanying this transmission may contain confidential health information that is legally protected. This information is intended only for the use of the individual or entity named above. The authorized recipient of this information isprohibited from disclosing this information to any other party unless permitted or required to do so by law or regulation. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance onthe contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
2016 Walgreen Co. All rights reserved.
30 mg 60 mg
Aranesp Neulasta Procrit Granix Neupogen Promacta
Daklinza
.//mg tablets
Zepatier 50mg/100mg tablets
Note: This form is intended for prescriber use only. If faxed, the fax must come from MD office or hospital (should not be faxed by patient).
90 mg
Epclusa mg/100mg tablets
Viekira XR .//mg and mg tablets 200/8.33/50/33.33mg tablets
DeBoardTTypewritten Text
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Specialty Care Center: Patients Home: toggle_3: Other: undefined: Patient Name: DOB: undefined_2: Address: City: State: Zip Code: Phone Daytime: Phone Evening: Email Address: Insurance Provider Please include copy of front and back of card: ID: PolicyGroup: Phone: Name of Insured: Employer: Self: No: Other_2: undefined_3: Patient is Eligible for Medicare: Yes: Carrier: PolicyGroup_2: Patient is Naive: Patient is a Null Responder: Primary Diagnosis Code: Patient is a Relapser: toggle_16: fill_60: fill_61: fill_62: toggle_17: fill_63: fill_64: fill_65: Current Weight: Date: fill_66: fill_67: fill_68: Height pediatrics: Date_2: toggle_21: toggle_22: toggle_23: toggle_24: toggle_25: toggle_26: toggle_27: toggle_30: Ribasphere: toggle_29: fill_72: fill_73: fill_74: Initial Viral Load: No_2: Yes with: toggle_32: toggle_33: toggle_35: toggle_36: Ribasphere Ribapak: Date of Initial Viral Load: undefined_4: fill_75: fill_76: fill_77: Fibrosis Score: Cirrhosis: Decompensated: toggle_38: toggle_39: fill_78: fill_79: fill_80: Other Health Conditions 1: Other Health Conditions 2: toggle_42: toggle_43: toggle_44: toggle_45: fill_81: fill_82: fill_83: Allergies 1: Allergies 2: Concomitant Medications 1: Concomitant Medications 2: Procrit: undefined_6: Promacta: DirectionsFreqAranesp Neulasta Procrit Granix Neupogen Promacta: QtyAranesp Neulasta Procrit Granix Neupogen Promacta: fill_89: Prescribers Name: PracticeFacility Name: Address_2: fill_41: City_2: State_2: Zip Code_2: Phone_2: Fax: Best Time to Call: State License: DEA: NPI: Medicaid UPIN: fill_52: Date_3: Date_4: Fax #: []Phone #: []Provider Rep: Rep Phone: Date Needed: Neulasta: Neupogen: Aranesp: Granix: toggle_28: Moderiba: Moderiba Pak: PRESCRIPTION INFORMATION: Technivie: Daklinza 30mg: toggle_14: Zepatier: fill_69: fill_70: fill_71: fill_57: fill_58: fill_59: Daklinza 60mg: toggle_19: Blank Line: toggle: toggle2: toggle3:
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