Medcartpharmacy.com

Toll Free Phone:
877.770.4MEDS(4633)
Toll Free Fax: 877.771.4MEDS(4633) www.medcartpharmacy.com Patient’s Information Name: _________________________________________________________________________________________________
Patient SS#: ____________________________ DOB:________________ Weight:________________ Height:________________ q Male q Female Allergies: _____________________________________________________________________________________________________________ q Latex
Address: __________________________________ City: ___________________________________________________ State: ________ Zip: ___________ Home Phone: ______________________________ Work Phone: _______________________________ Cell Phone: _________________________ q Text Specialty Physician Information Name: _____________________________________________________________________________________
State License #: ________________ UPIN: _________________________ DEA #: ___________________________ NPI #: _______________________ Group or Hospital: _________________________ Phone: _________________________________________________ Fax: _________________________ Address: __________________________________ City: ___________________________________________________ State: ________ Zip: ___________ Contact Person: ____________________________ Phone: _______________________________________________________________________________ Primary Care Physician information Name: _________________________________________ Phone: __________________________________
Insurance Information (Fax copy of patient’s insurance card - both sides)St
Current Medications:
Comorbid Diseases:
_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ q Other ___________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Patient Assessment – Hep C:
HCV RNA (Baseline) ________________ IU/ml Date of Lab:________________
HCV RNA (12 weeks, if applicable) ________________ IU/ml Date of Lab:________________ Statement of Medical Necessity
HCV Genotype: q1a q1b q2 q3 q4 q5 q6 Pre-Treatment ALT: ________________ Diagnosis (ICD-9 code):
Patient Evaluation – HIV:
Has patient been previously treated for Hepatitis C? q Yes q No Has patient had liver biopsy? q Yes q No • Biopsy date/Results: ________________ ________________ CD4/T-cell count: ______________________________________ Does patient suffer from uncontrolled/life-threatening neuropsychiatric, autoimmune, ischemic, or infectious disorders, or have a history of autoimmune hepatitis or hepatic decompensation? q Yes q No If taking ribavirin, is the patient (or patient’s partner) pregnant or unwilling to use adequate contraception, White blood cell ct: ______________________________________ or is there a history of hemoglobinopathies or renal insufficiency (crcl<50ml/min)? q Yes q No Prescription Information
HIV Medications
HIV Medications Continued
Medication Strength Directions/Signature
Qty Refill Medication Strength Directions/Signature
Qty Refill
Hepatitis C Medications
Please indicate conv. Pack (includes injection supplies) q Prefilled Syringe q Vial Please indicate kit (includes injection supplies) q Redipen® q Vial Hepatitis B Medications
Other Medications
Ancillary Supplies and Kits Provided As Needed for Administration Product Substitution Permitted Signature Date Dispense As Written Signature Date Ship To: q Patient q Physician/Clinic Date: __________________________________________ Date Shipment Needed: ________________________________________ Rx: q New q Refill Injection Training/Home Health Coordination: Physician Signature required. q Patient’s Home or Clinic Site q Physician’s Office q No Nurse
Specialty Physician’s name: (please print): ___________________________ Phone: _________________________________________________________ NPI #: __________________________________________________________ Specialty Physician’s signature: _______________________________ M.D.
q Injection training is not necessary. Date training occurred: ______________________________________________________________________________
q MD office trained patient q Patient already independent q Referred by MD office to alternate trainer
I authorize MedCart Specialty Pharmacy and its representatives to act as an agent to initiate and execute the insurance prior authorization process.
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Source: http://www.medcartpharmacy.com/wp-content/uploads/2012/01/10_1_13-HIV-Co-New.pdf