P rescriber (print): __________________________________________________________ O ffice contact: __________________________________________ P referred method of contact: P hone F ax E mail P referred contact persons email: ______________________________________________________ S hip to: P atient O ffice A lternate ________________________________________________________________________________________________ O ffice address: _____________________________________________________________________________________________________________________ Current medications (if necessary, please fax copy of complete list): _______________________________________________________________________ Diagnosis/ICD-10: B18.0 Hepatitis B (with delta agent) B18.1 Hepatitis B (without delta agent) other: ________________________________ male female lbs kg cell NKDA last name, first name street city state zip P hone: ___________________________ F ax: ______________________________ NPI: ___________________________ DEA: ________________________ P rescriber’s signature: __________________________________________________________________________________ D ate: _______________________ I authorize Metro Drugs , LLC . and its representatives to act as an agent to initiate and execute the insurance prior authorization process for this prescription and any future fills of the same prescription for the patient listed above. I understand that I can revoke this designation at any time by providing written notice to Metro Drugs Pharmacy, LLC. shipping address: street city state zip Previously treated with interferon? ( Y / N ) Start date of hep B therapy: ______________________________________ Pre-treatment ALT: _____________________________ D ate: _____________ Most recent ALT: ______________________________ D ate: _____________ Pre-treatment HBV viral load: ________________ D ate: _____________ ANC: ________________________________________ /mm 3 D ate: _____________ Liver biopsy: ( Y / N ) results: _____________ D ate: _____________ Hgb: ________________________________________ g/dL D ate: _____________ Patient Information P atient: ____________________________________________________________ DOB: _____________ SS#: ____________________________ A ddress: ____________________________________________________________________________________________________________________________ P rimary phone number: _____________________________ cell A lternate phone number: _______________________________________________ C aregiver: ________________________________________________________________ A llergies: __________________________________________ C omorbidities: ____________________________ H eight:__________ W eight: ________________ D ate: ____________________________________ Clinical Information P rescriber + S hipping I nformation I nsurance I nformation: P lease fax copy of insurance card (front + back) Prescription Strength Directions Quantity Refills Hepsera ® 10 mg Take 1 tablet by mouth once daily 30 Baraclude ® 0.5 mg 1 mg Take 1 tablet by mouth once daily 30 Tyzeka ® 600 mg Take 1 tablet by mouth once daily 30 Epivir-HBV ® 100 mg Take 1 tablet by mouth once daily 30 Viread ® 300 mg Take 1 tablet by mouth once daily 30 Updated o n 9/2017 (street, suite, city, state, zip) CONFIDENTIALITY NOTICE: This fax is for use only by the person named above. It is private. It may be subject to HIPAA Privacy and security rules. You may not use, copy or share this fax without permission. Please call us at (877) 577-1447 if you received this fax by mistake. Do not destroy this fax until you have spoken with us. We may ask you to destroy or return the fax to us. Thank you for your cooperation. Metro Drugs Pharmacy LLC. Hepatitis B Referral Form Fax Referrals To: ( 718 ) 795-1639 Vemlidy ® 30 Take 1 tablet by mouth once daily 25 mg Metro Drugs Pharmacy 134-02 Jamaica Avenue Queens, NY 11418 Phone : 718-206-4653