HEPATOLOGY New Orleans, LA: toll free 888.355.4191 toll free fax 888.355.4192 tlcrxpharmacy.com DATE: _______________ NEEDS BY DATE: ______________ SHIP TO: o PATIENT o OFFICE o OTHER _______________________________________________________________ PATIENT INFO PRESCRIBER INFO Patient Name Prescriber Name Address DEA # City, State, Zip Address Main Phone Alternate Phone NPI # City, State, Zip Social Security # Phone Date of Birth License # o Male o Female Fax Contact Person INSURANCE: PLEASE FAX COPY OF PRESCRIPTION CARD & MEDICAL CARD FRONT & BACK CLINICAL INFORMATION o 070.54 Chronic Hepatitis C o 572.2 Hepatic Encephalopathy o 155.0 Hepatocellular Carcinoma o Other: _________________________________________________________ Genotype: o 1 o 1a (Q80K Polymorphism: o Yes o No) o 1b o 2 o 2a o 2b o 3 o 3a o 3b o 4 o 4a o 4b Viral Load:_________________ IU/ml Viral Load Date :__________ o Treatment Naive o Previously Treated: Prior treatment used: ______________________________________________________ o Non-Responder Duration of previous therapy: From _____________________ to ___________________ Total of: _________ months HIV Coinfected: o Yes o No Compensated Liver Disease: o Yes o No Cirrhosis: o Yes o No Metavir Score: ______ Solid Organ Transplant recipient: o Yes o No o Take 1 tablet by mouth daily with or without food oSovaldi® 400mg Tablet o Take 1 tablet by mouth once per day HBV Coinfected: o Yes o No Awaiting Liver Transplant?: o Yes o No PRESCRIPTION INFORMATION oHarvoni® 90mg/400mg Tablet o Responder/Relapser o Take 2 tablets (ombitasvir/paritaprevir/ritonavir) once daily in the morning and 1 tablet (dasabuvir) twice daily in the morning and evening with a meal as directed by the Pak oModeriba 200mg Tablet o 600mg AM and 600mg PM (1200mg) o 600mg AM and 400mg PM (1000mg) oRibavirin 200mg Tablet o 400mg AM and 400mg PM (800mg) o 400mg AM and 200mg PM (600mg) oRibavirin 200mg Capsule o Other: Take ___________ mg AM and ________________ mg PM QUANTITY REFILLS 28 day supply ___________ 28 day supply ___________ oViekira Pak® 28 day supply ___________ 28 day supply ___________ oRiba-Pak® (ribavirin) o 600mg AM and 600mg PM (1200mg) o 600mg AM and 400mg PM (1000mg) oModeriba Pak® (ribavirin) o 400mg AM and 400mg PM (800mg) o 400mg AM and 200mg PM (600mg) oOlysio® 150mg Capsule o Take 1 capsule by mouth once per day with food 28 day supply ___________ o Pegasys® o PFS o ProClick Inject: o 180mcg subcutaneously weekly o 135mcg subcutaneously weekly o 90mcg subcutaneously weekly 28 day supply ___________ oPeg-Intron® Redipen Less than 88lbs 89-111 Less than 40kg 50mcg/0.5 ml 40-50 80mcg/0.5 ml 28 day supply ___________ o 50mcg (0.5 ml) subcutaneously weekly o 64mcg (0.4 ml) subcutaneously weekly 112-133 51-60 o 80mcg (0.5 ml) subcutaneously weekly 134-166 61-75 120mcg/0.5 ml o 96mcg (0.4 ml) subcutaneously weekly 167-187 76-85 o 120mcg (0.5 ml) subcutaneously weekly greater than 187 greater than 85 150mcg/0.5 ml o 150mcg (0.5 ml) subcutaneously weekly 28 day supply ___________ o Procrit Inject: o 40,000 units subcutaneously every week o other: ______________________________ 28 day supply ___________ o Neupogen SingleJect Inject: o 300mcg o 480 mcg subcutaneously o every week o twice weekly o three times weekly 28 day supply ___________ o Xifaxan 550mg Tablet o Take 1 tablet by mouth twice daily 30 day supply ___________ By signing this form and utilizing our services, you are authorizing TLCRxTM and it’s employees to serve as your prior authorization designated agent in dealing with medical and prescription insurance companies. **indicate previously failed therapy (Lactulose) _______ _______________________________________________________________ _______________ Prescriber’s Signature (no stamps) If Brand required check o DAW Date IMPORTANT NOTICE: This fax is intended to be delivered only to the named addressee. It contains material that is confidential, privileged property or exempt from disclosure under applicable law. If you are not the named addresses you should not disseminate, distribute or copy this fax. Please notify the sender immediately if you have received this document in error and then destroy this document immediately. 12-22-2014 LA
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