Toll Free Phone:
Toll Free Fax: 877.771.4MEDS(4633) 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.
IMPORTANT NOTICE: This message is intended for use of only the named addressee and may contain information that is proprietary and confidential. If it is received by anyone other than the
named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other than the named addressee, except by express authority of the sender to the named addressee.
Reset All Fields


First Time Buyers Well done! The decision to buy a home has proven to be one of the best made for millions of happy home owners. It’s a fact that property is a good investment, especially when you compare it to paying rent. It is important, however to enter the property market with a good understanding of how a property purchase works, what your costs will be and a respect that this is prob


Human intestinal bacteria as reservoirsfor antibiotic resistance genesAbigail A. Salyers, Anamika Gupta and Yanping WangDepartment of Microbiology, University of Illinois, Urbana, IL 61801, USAHuman intestinal bacteria have many roles in humanthrough the human colon on a regular basis are pathogenshealth, most of which are beneficial or neutral for thesuch as Streptococcus pneumoniae and

© 2010-2017 Pharmacy Pills Pdf