HEPATITIS B ENROLLMENT FORM

Form Name

E-Prescribing is encouraged for quicker turnaround time for our patients.

See our e-prescribe information below!

Patient Information

Patient Name:*

First and Last Name

Date of Birth:*

Date

Gender:

MaleFemaleOtherPrefer Not to Say

Address

Street Address Line 2

CityState

Zip

Phone Number:

Alt. Phone Number:

Language:

Allergies:*

If No Know Drug Allergies, please put N/A

Height:

Weight:

SSN:

Product Shipping Options:

Patient’s HomePrescriber OfficeAlternative Address:

Alt. Address

Street Address

Street Address Line 2

CityState

Zip Code

Prescriber Information

Prescriber:*

Prescriber PIN:*

Please provide your verification PIN. For those new to our pharmacy, please put 11111 and we'll reach out to you to set up a PIN.

NPI:*

DEA:

Phone Number:*

Fax Number:

Practice Name:

Office Contact:

Practice Address

Street Address

Street Address Line 2

CityState

Zip Code

Clinical Information

Please provide all available chart notes, including lab Results:

ICD-10/Diagnosis:

B18.1 (Chronic HBV)Other:

Does the patient have cirrhosis?

NoCompensatedDecompensated

Co-Infections:

NoneHIVHepatitis C

Has the patient been HBsAg positive for at least 6 months?

YesNo

Is the patient HBeAg positive?

YesNo

Has the patient had a persistent serum ALT > 2 times above upper limits of normal (ULN)?

YesNo

Prior Failed Therapy:

Has the patient had a liver transplant?

YesNo

Is the patient awaiting a liver transplant?

YesNo

No HBV DNA Level:

Prescription Information

Medication

Baraclude® (entecavir)Vemlidy® (tenofovir alafenamide)Epivir-HBV® (lamivudine)Hepsera® (adefovir dipivoxil)Pegasys® (pegylated interferon)Viread® (tenofovir disoproxil fumarate)

Baraclude Dose:

0.5 mg tablet1 mg tablet

Directions: Take one tablet by mouth daily without food.

Quantity: 30

Refills:# Refills

Vemildy Rx Info

Dose: 25 mg tablet

Directions: Take one tablet by mouth daily with food.

Quantity: 30

Refills: # Refills

Epivir-HBV® (lamivudine) Rx Info

Dose: 100 mg tablet

Directions: Take one tablet by mouth daily.

Quantity: 30

Refills: # Refills

Hepsera® (adefovir dipivoxil) Rx Info

Dose: 10 mg tablet

Directions: Take one tablet by mouth daily.

Quantity: 30

Refills: # Refills

Pegasys® (pegylated interferon) Dose:

180 mcg/0.5 mL PFS180 mcg/0.5 mL vial180 mcg/0.5 mL ProClick

Directions: Inject 180 mcg sub-Q once weekly for 48 weeks

Quantity: 4 PFS

Refills:# Refills

Viread® (tenofovir disoproxil fumarate) Rx Info

Dose: 300 mg tablet

Directions: Take one tablet by mouth daily.

Quantity: 30

Refills: # Refills

PRESCRIBER SIGNATURE

(Please sign and date below)

Prescriber Authorization: I authorize this pharmacy and its representatives to act as my authorized agent to secure coverage and initiate the insurance prior authorization process for my patient(s), to sign any necessary forms on my behalf as my authorized agent, including the receipt of any required prior authorization forms, the receipt and submission of patient lab values and other patient data including pursuing available copay and financial assistance on behalf of my patients. If this pharmacy determines that it is unable to fulfill this prescription, I further authorize this pharmacy to forward this information and any related materials related to coverage of the product to another pharmacy of the patient’s choice or in the patient’s insurer’s provider network.

Substitution Preferences

Product substitution permittedDispense as WrittenTherapeutic substitution permitted

Signature

Date

CONFIDENTIALITY NOTICE: This form and its contents may contain private and confidential information that is intended for the individual or entity to which it is addressed. Any transmission of this form may contain information that is exempt from disclosure under laws including but not limited to the Health Insurance Portability and Accountability Act (HIPAA Unless explicitly stated, you are strictly prohibited from disseminating, copying or distributing any material contained within. Violators will be prosecuted to the fullest extent of the law. If you received this communication in error, please notify us immediately and destroy this form and its contents.