Follow the steps to complete the WI DHS F-01247 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section I, Member Information. Enter the member's name (last, first, middle initial), member identification number, and date of birth.
3. Proceed to Section II, Prescription Information. Fill out the date the prescription was written, the prescriber's name, National Provider Identifier, address, and telephone number. Indicate the member's proposed hepatitis C drug treatment regimen, including drug names, whether currently taking them, daily doses, and expected durations.
4. Move to Section III, Clinical Information. Enter the diagnosis code and description. Note that a copy of current medical records must be submitted, including specific assessments and lab data.
5. Continue in Section III by answering questions about the prescriber's board certification, the member's hepatitis C diagnosis date, likely source of infection, and HCV genotype and subtype.
6. Complete the required questions regarding the member's drug treatment history, any previous infections, and assessments related to liver health and alcohol use.
7. If applicable, fill in additional clinical information required for members with cirrhosis in Section III A.
8. Sign and date the form in Section IV, Authorized Signature. Ensure compliance with all required submissions.
9. Review all entered information for accuracy. Save changes and choose to download, print, or share the completed form as needed.

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