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Dolphin’s Hepatitis C Checklist
© 2020. Dolphin Health Specialty Pharmacy. All rights reserved.
Please make sure you send all of the following in one fax if possible. This will help expedite our eligibility and prior authorization process.
What is attached?
❑ Demographics
❑ Last 2 Visit Notes
❑ Fibrosis documentation (biopsy, fibroscan, fibrosure)
❑ HCV Genotype
❑ HBV (*if available)
Last 90 days:
❑ HCV RNA Viral Load (last 90 days)❑ CBC w/ PLT (last 90 days)❑ Complete Metabolic Panel (last 90 days)
❑ Imaging (*if available)
❑ PT/INR (*if cirrhotic)
❑ NS5A Resistance Testing for GT1A and GT3
❑ Current Medications
❑ Patient Adherence / readiness documentation
Special Comments or Requests
www.dolphinhealth.com
Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605
Page 1 of 3
PLEASE ATTACH FRONT AND BACK OF THE PATIENT’S INSURANCE CARD
FRONT
BACK
Sender
ATTN:
Hepatitis C Form
© 2020. Dolphin Health Specialty Pharmacy. All rights reserved Updated 4/23/2020. Page 2 of 3
www.dolphinhealth.com
Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605
1
Provider InfoName Contact
NPI DEA LIC
Address City State, Zip
Phone Extension Fax
Coordination
Today Need By RX Type ❑ New ❑ Refill
Ship To ❑ All fills to Patient ❑ 1st fill to Clinic ❑ All fills to Clinic q Other Training By ❑ Dolphin ❑ Clinic ❑ N/a
Insurance ❑ Commercial ❑ Medicare ❑ Medicaid ❑ Cash Patient Impaired ❑ Hearing ❑ Vision
Patient Info
Name DOB SSN
Address City State, Zip
Phone Caretaker Language
Email Height ❑ In ❑ cm Weight ❑ lb ❑ kg
Tried & Failed
Medication Start Date End Date Reason for Discontinuation
Non-Adherence Concerns?
Hepatitis C Form
Clinical
Diagnosis q B18.2 Chronic Hepatitis C Diagnosis Date:
Genotype: q 1a q 1b q 2 q 3 q 4 q 5 q 6 Cirrhosis q None q Compensated q Decompensated
Fibrosis: q F0 q F1 q F2 q F3 q F4 Baseline Viral Load: _______ IU/mL
Baseline Viral Load Date: Co-Infection q HBV q HIV q N/a
Polymorphism: q NS5A q IL28B q Q80K q N/a Treatment Naive q Yes q No
Hepatitis B Screening q Yes q No Ethnicity:
Allergies Concurrent Medications:
Comorbidities:
q Type 2 DMq Debilitating Fatigueq HIV
Elevated Risk of Transmission
q Women; child bearing, wishing to get pregnantq HCV infected healthcare worker, performs exposed prone proceduresq MSM w/ high risk sexual practicesq Long-term HD
Extrahepatic Manifestations
q Porphyria Cutanea Cardaq HCV-related kidney Diseaseq Symptomatic Cryoglobulinemia
Date:
© 2020. Dolphin Health Specialty Pharmacy. All rights reserved Updated 4/23/2020.
www.dolphinhealth.com
Page 3 of 3
Signature
By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to Dolphin Health to act as the prescriber’s agent to begin and to execute the prior authorization process and to help the patient apply to co-pay assistance programs, including all foundations and manufacturer programs if necessary.
Provider Date q Do Not Substitute
Phone: (510) 900 – 3131 Fax: (844) 329-6979 7400 MacArthur Blvd, Suite A, Oakland, CA, 94605
Verify
Patient DOB Provider Date
Hepatitis C Form
Prescription
Medication Strength Directions Duration QTY REFILLS
❑ Epclusa ® ❑ 400/100mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 24 28
❑ Harvoni ® ❑ 400/90mg ❑ Take 1 tablet by mouth ONCE daily.q 8q 12q 24
28
❑ Mavyret ® ❑ 100/40mg ❑ Take 3 tablets by mouth ONCE daily.q 8q 12q 16
84
❑ Sovaldi ® ❑ 400mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 24 28
❑ Vosevi ® ❑ 400/100/100mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 24 28
❑ Zepatier ❑ 50/100mg ❑ Take 1 tablet by mouth ONCE daily. q 12q 16 28
❑ Ribapak❑ DAW1
❑ 600 mg❑ 800 mg❑ 1,000 mg❑ 1,200 mg
❑ Take ________ mg QAM, _______mg QPM, with food q 12q 24
❑ Ribasphere
Tablets
❑ 200mg❑ 400mg❑ 600mg
❑ Take ________ mg QAM, _______mg QPM, with food q 12q 24