Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Start by filling in Section I – Member Information. Enter the member's name as Last, First, and Middle Initial, followed by the Member ID Number and Date of Birth.
3. Proceed to Section II – Prescription Information. Input the Date Prescription Written, the Prescriber's Name, National Provider Identifier, Address, and Telephone Number.
4. Indicate the member’s proposed hepatitis C drug treatment regimen in this section. List each drug name, state if they are currently taking it, and provide the Daily Dose.
5. In Section III – Clinical Information, please enter the Diagnosis Code and Description. Ensure that you include copies of medical records that verify the information provided.
6. Fill out the subsequent questions regarding the member's hepatitis C diagnosis, genotype, previous treatments, and histories of alcohol or drug use.
7. If applicable, complete Section III A for members who have cirrhosis. Provide details regarding the Child-Turcotte-Pugh class, score, and additional conditions.
8. In Section IV, ensure that both the Prescriber’s signature and the date signed are included. This section validates the authorization request.
9. Finally, review all entries for accuracy and completeness. You can save changes, download, print, or share the form as needed.

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