Get Ny Fidelis Care Medication Request Form For Hepatitis C (hcv) Agents 2015-2025

Completing the NY Fidelis Care Medication Request Form for Hepatitis C (HCV) Agents online is a straightforward process that requires attention to detail. This guide will walk you through each section of the form to ensure accuracy and completeness.

Follow the steps to accurately complete the form.

1. Use the ‘Get Form’ button to access the NY Fidelis Care Medication Request Form for Hepatitis C (HCV) Agents online.
2. Fill in the member's personal information, including their full name, ID number, date of birth, age, height, weight, and sex.
3. Provide the prescriber’s details, including their full name, NPI number, contact person, address, phone number, and fax number.
4. Indicate the specialty of the prescriber such as Hepatologist, Gastroenterology, Transplant physician, or Infectious Disease, and provide the corresponding details.
5. Complete the HCV clinical experience section, documenting the prescriber's management of patients with HCV and any required continuing medical education credits.
6. Attach hard copies of clinical/chart notes and laboratory results that support the clinical criteria as requested in the form.
7. Detail the patient’s medical background, including Hepatitis C genotype, HCV RNA level, and hepatic fibrosis stage.
8. Describe any comorbid conditions affecting the patient and any prior treatment status or medications taken.
9. Indicate the requested medications, dosage, and expected duration of therapy.
10. Review the follow-up laboratory requirements and ensure they are documented appropriately.
11. Sign and date the prescriber’s signature section to authorize the information provided.
12. Finally, save changes, and decide to download, print, or share the completed form as needed.

Complete the NY Fidelis Care Medication Request Form online today to ensure timely processing of your medication request.