Hepatitis C Enrollment Form

Hepatitis C Enrollment Form

Form will be automatically sent to Sunray Specialty Pharmacy for processing. Please send an electronic prescription along with this form to avoid delays.
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Phone Number
Please enter a valid phone number.
Patient's Height*
Patient's Weight*
Allergies to Medications*
Concomitant Medications*
Prescriber*
Which medication is being prescribed for the patient?*

Epclusa (or authorized generic)MavyretVoseviOther
Did the patient already begin therapy?*

YesNo
When did the patient begin therapy?*

MonthDayYear
Date
Is medication to be delivered to the patient's address or the office?*
When would you like the medication delivered to the office?*

MonthDayYear
Date
How long will the patient take the medication?*

8 weeks12 weeks16 weeksOther
Has the patient been treated for hepatitis C in the past?*

YesNo
What medication(s) did the patient take previously?

Peg-interferonHarvoniEpclusaMavyretUnsureOther
How long did the patient take this medication? (if multiple medications, please specify for each)
What was the result of the previous treatment(s)?

Treatment complete and SVR-12 achievedTreatment complete but SVR-12 was not achievedTreatment incomplete due to adherenceOther
What is the HCV genotype?*

1a1b23456Unknown
What is the HCV viral load?*
What is the patient's FIB-4 score?*
Does the patient have HIV?*

YesNo
Does the patient have hepatitis B?*

YesNo
When will the patient be returning to start therapy?

MonthDayYear
Date
Please upload the following labs and documentation or fax to (215)471-4001: HCV RNA, FIB-4 score (documented in notes is acceptable), genotype (if required), RAS testing (if required), and HIV screening. If writing for non-preferred agent (Vosevi), please include documentation of past treatment(s). Prior authorization requests cannot be processed without labs and documentation.

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