Hepatitis C & Hepatitis B
Enrollment Form /

280 Avenida Jesus T. Pinero, Suite B

Rio Piedras, PR 00927
Fax Referral To: 888-280-1191
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Local Phone: 787-759-4162
Local Fax: 787-759-4090
Toll Free Phone: 888-280-1190 /
Date:
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Needs by Date:
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Ship to: Patient Office Other:

PATIENT INFORMATION

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PRESCRIBER INFORMATION

(Complete the following or send patient demographic sheet) / Prescriber’s Name:
Patient Name: / State License #: / UPIN:
Address: / DEA #: / NPI #:
City, State, Zip: / Group or Hospital:
Home Phone: / Address:
Alternate Phone: / City, State Zip:
SS #: / Phone: / Fax:
Date of Birth: / Gender: / Contact Person: / Phone:

INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card)

Prescription Card: / Name of Insurer: / ID#: / BIN: / PCN: / Group:
Primary Insurance: / Subscriber: / ID#: / Name of Insurer: / Phone:
Secondary Insurance: / Subscriber: / ID#: / Name of Insurer: / Phone:
STATEMENT OF MEDICAL NECESSITY
Diagnosis (ICD-9 code): / Injection Training/Home Health Coordination:
070.54 Hepatitis C (chronic) 070.32 Hepatitis B · Date of Diagnosis: / · Specialty Pharmacy to coordinate injection training/home health nurse visit
Patient Evaluation: / as necessary. Yes No *Agency of choice:
· HCV RNA (Baseline) / IU/ml · Date of Lab: / · Injection training is not necessary. Date training occurred:
· HCV RNA (after 12 weeks treatment, if applicable) / IU/ml · Date of Lab: / Reason: MD office trained patient Patient already independent
· HCV Genotype: 1a 1b 2 3 4 5 6 / Referred by MD office to alternate trainer
· Has patient been previously treated for Hepatitis C? Yes No
· Has patient had liver biopsy? Yes No *If Yes, Results: / · Date of Biopsy:
· Does the patient suffer from uncontrolled or life-threatening neuropsychiatric, autoimmune, ischemic, or infectious disorders, or does the patient have a history of autoimmune hepatitis or hepatic
decompensation? Yes No
· If taking ribavirin, is the patient (or patient’s partner) pregnant or unwilling to use adequate contraception, or is there a history of hemoglobinopathies or renal insufficiency (crcl < 50ml/min)? Y N
· Patient weight: / kg/lbs · Pre-Treatment ALT: / · Length of Treatment:
· Allergies: / · Concomitant Medications:
PRESCRIPTION INFORMATION
PEGASYSâ / RIBASPHERE
180ug/0.5ml Prefilled Syringe 180ug/1ml Vial / 200mg tablets 200mg capsules
Directions: Inject 180ug subcutaneously once a week as directed / Directions: Take / tabs/caps po qam and / tabs/caps po qpm.
Other: / Quantity: / Refills:
Quantity: / Refills: / RIBA-PAKÔ (generic ribavirin) tablet dose pack
PEGINTRONÔ / Directions:
Redipenâ Vial / Take 600mg tabpo qam and600mg tabpo qpm =1200/day (600-600)
Take 600mg tabpo qam and400mg tabpo qpm =1000/day (600-400)
PegIntronÔ dosing based on 1.5ug/kg week in combination with Ribavirin / Take 400mg tabpo qam and400mg tabpo qpm =800/day (400-400)
Weight / Redipenâ/Vial Strength or Size / Directions / Quantity: / Refills:
<88lbs / 50/0.5 / Inject 0.5ml subcutaneously once a week. / HEPATITIS B ORAL THERAPIES
89-110lbs / 80/0.5 / Inject 0.4ml subcutaneously once a week. / Baracludeâ 0.5mg / Baracludeâ 1mg
111-132lbs / 80/0.5 / Inject 0.5ml subcutaneously once a week. / Hepseraâ 10mg / Epivir HBVâ 100mg
133-165lbs / 120/0.5 / Inject 0.4ml subcutaneously once a week. / Tyzekaâ 600mg / Vireadâ
166-187lbs / 120/0.5 / Inject 0.5ml subcutaneously once a week. / Directions: 1 tablet po QD Other:
>187lbs / 150/0.5 / Inject 0.5ml subcutaneously once a week. / Quantity: / Refills:
Other: / OTHER MEDICATIONS
Quantity: / Refills:
INFERGENâ
15ug/0.5ml vial 9ug/0.3ml vial
Directions: / Inject 15ug subcutaneously three times a week. / Directions:
Inject 9ug subcutaneously three times a week. / Quantity: / Refills:
Other:
Quantity: / Refills: / Ancillary Supplies and Kits Provided As Needed for Administration
I hereby freely and voluntarily have selected CVS Caremark and/or CarePlus CVS/pharmacy to dispense the medication herein prescribed by my physician.
Patient Signature: ______
PRODUCT SUBSTITUTION PERMITTED (Date) / DISPENSE AS WRITTEN (Date)

IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee. Hepatitis 092910