Ship to: Patient Physician 1st order only Physician all orders  Other___________________ Need Nurse Need Training  Enroll patient in advanced case management services (see your AcariaHealth representative for details) Phone: 800-511-5144 Fax: 877-541-1503 Hepatitis C Referral Form Patient Name: ___________________________________________________ Address:_______________________________________________________ City: State: _________ Zip: _____________ Home Phone: (__________) ______________ - _______________________ Work Phone: (__________) ______________ - _______________________ Cell Phone: (__________) ______________ - _______________________ Patient Soc. Sec #:____________________Allergies:_____________________ Date of Birth:_____/_____/_____Sex: Male Female Weight:___ lbs ___ kg Physician Name:_________________________________________________ Patient ethnicity:______________________________________________________  See attached demographic sheet Height:______ BSA______ m² Physician’s Fax: (__________) ____________ - _______________________ State Lic # _____________________ DEA # __________________________ NPI # _________________________ Specialty: ________________________ Practice Name/Hospital: ___________________________________________ Address:_______________________________________________________ City: _______________________________State: _______Zip:____________ Physician’s Ph: (__________) ____________ - ________________________ Nurse/Key Office Contact: __________________________________________ Primary Insurance:___________________ INSURANCE INFORMATION (Please Attach Copies of front and back of cards) Secondary Insurance:________________ Rx Card (PBM):_____________________ Cardholder First Name: _______________ City:______________State:___________ City:______________State:___________ PBM BIN: _________________________ Last Name: ________________________ Plan #: ___________________________ Plan #: ___________________________ City:______________State:___________ Employer: _________________________ Group #: __________________________ Group #: __________________________ Group #: __________________________ ID #: _____________________________ Phone: (______) ________-__________ Phone: (______) ________-__________ Phone: (______) ________-__________ Group #: __________________________ DIAGNOSTIC INFORMATION Please Fax Medication Profile to AcariaHealth 070.54 Hepatitis C (Chronic) Other ICD 9 __________ Genotype: 1 1a 1b 2 2a 2b 3 3a 3b 4 4a 4b 5  6 Other______________________ Viral Load: __________________________ Treatment Naïve Previous treatment: ________________________Non-Responder Partial Responder Responder/Relapser Duration of prior treatment: From ______________ To _____________ Total of _________ Weeks Co-infected with: HIV HBV N/A Cirrhosis: Compensated De-compensated History of liver biopsy?: Yes No N/A Fibrosis present?: Yes No N/A History of liver test?: Yes No N/A Fibro score: ______ N/A IL28B genotype ______ Transplant Patient  Yes No Interferon intolerant  Yes No Q80K polymorphism present?: Yes No N/A  Labs: to be performed prior to therapy and monitored during treatment at appropriate intervals (particularly pregnancy test for woman of childbearing potential) ALT ____ AST_____ Hgb____ Plt_____ Serum creatinine___________date of last laboratory draw ___________  Other medications patient is currently taking (including OTC medications): _______________________________________________________________________________  Other disease states: Depression Anxiety Diabetes Other _________________________________________________________________________________________ PRESCRIPTION INFORMATION □ Sovaldi® □ (sofosbuvir) 400mg 1 tablet PO once daily Supply: 1 mo Refill: Supply: 1 mo Refill: □ Olysio® (simeprevir) 150mg 1 capsule PO once daily 1 tablet PO once daily Supply: 1 mo □ OK to substitute Ribapak/Moderiba with Ribavirin if non-formulary □ □ Harvoni® (ledipasvir / sofosbuvir) 90mg/400mg Refill:______ RIBAPAK® □ MODERIBA® □ RIBAVIRIN 200mg □ 400mg PO QAM; 200mg PO QPM Supply: 1 mo Refill: □ 400mg PO QAM; 400mg PO QPM Supply: 1 mo Refill: □ 600mg PO QAM; 400mg PO QPM Supply: 1 mo Refill: □ 600mg PO QAM; 600mg PO QPM Supply: 1 mo Refill: □ Other:_______________________ Supply: 1 mo Refill:______ Other*__________________________________________ ____________________________ Supply: 1 mo Refill: ks I authorize any division of AcariaHealth to enroll me in a manufacturer-assisted patient support program, corresponding with my prescribed therapy for purposes of receiving additional services such as, but not limited to: injection training. I further authorize the release to the corresponding manufacturer the minimum necessary information about my health condition a nd prescriptions to: coordinate the delivery of products and services available through the patient assistance program , aggregate de-identified data for market analysis, and provide educational information regarding therapies. I understand that I may revoke this authorization at anytime in writing by sending a letter to AcariaHealth 2301 Caroline St., Houston, TX77004. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment  fromDAW the pharmacy. (Dispense as Written) A copy of this authorization will be utilized with the same effectiveness as the original. ______________________________________________ ______________________ Patient Signature (required for participation) Date Physician’s Signature: ____________________________________ Date____/_____/____ Physician’s Signature: ____________________________________ DAW (Dispense as Written) Date____/_____/____ Prescriber certifies that this referral form contains an original signature and is signed by the treating physician IMPORTANT NOTICE: This message may contain privileged and confidential information and is intended only for the individual named. If you are not the named addressee, you should not disseminate, distribute or copy this fax. Please notify the sender immediately if you have received this document by mistake, then destroy this document. Please direct all verification or notification to AcariaHealth or any of its subsidiaries using the contact information provided on this coversheet. Rev.: 10/10/2014