Get Hepatitis C Referral Form

This guide provides clear instructions on completing the Hepatitis C Referral Form online. By following these steps, you can ensure that all necessary information is accurately captured and submitted effectively.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter today's date at the top of the form to indicate when the referral is being made.
3. Indicate whether the patient is a current or new patient by checking the appropriate box.
4. Complete the patient’s details, including first, middle, and last name, date of birth, emergency phone number, and address details.
5. Provide multiple phone numbers for the patient, including daytime, evening, and cell, as well as an email address for contact purposes.
6. Select the preferred shipping method for the prescription: whether it should be sent to the patient's home or work, or if the patient will pick it up.
7. List any known allergies, comorbidities, and current medications. If necessary, consider faxing a complete medication list.
8. Indicate if the patient has been previously treated for Hepatitis C and provide details on any drugs used.
9. Fill in the relevant medical criteria, including ICD-9 code, liver biopsy details, and any lab results such as HCV viral load.
10. Detail the insurance information, including the insured's name, relationship to the patient, and prescription card details if applicable.
11. Provide the prescriber’s details, including their name, address, contact information, and professional identifiers.
12. Complete the prescription section, including indications, medication, dosage, directions, quantity, and refills as necessary.
13. If applicable, indicate the request for patient training and the preferred method of office contact.
14. Sign the form to authorize Glen Rock Medical Pharmacy and its employees to act as your designated agent for prior authorization.
15. After completing the form, save changes, download a copy for your records, print, or share it as needed.

Complete the HEPATITIS C REFERRAL FORM online today to ensure timely processing of your medical needs.