Hepatitis B Metro Drugs Pharmacy Referral Form 134-02 Jamaica Avenue Queens, NY 11418 Fax Referrals To: (718) 795-1639 Phone : 718-206-4653 Patient Information male Patient: ____________________________________________________________ female DOB:______________ SS#: _____________________________ last name, first name Address: ____________________________________________________________________________________________________________________________ street city state zip Primary phone number: _____________________________ cell cell Caregiver: ________________________________________________________________ Allergies: __________________________________________ NKDA lbs Comorbidities: ____________________________ Height:__________ Weight: ________________ kg Date: ____________________________________ Clinical Information 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:_________________________________ Previously treated with interferon? ( Y/ N) Pre-treatment HBV viral load: ________________ Date: _____________ Start date of hep B therapy: ______________________________________ ANC: ________________________________________ /mm3 Date: _____________ Pre-treatment ALT:_____________________________ Date: _____________ Liver biopsy: ( Y/ N ) results: _____________ Date: _____________ Most recent ALT: ______________________________ Date: _____________ g/dL Hgb: ________________________________________ Date: _____________ Prescription Strength Directions Quantity Refills 10 mg Hepsera® Take 1 tablet by mouth once daily 30 0.5 mg Baraclude® Take 1 tablet by mouth once daily 30 1 mg 600 mg Take 1 tablet by mouth once daily 30 Tyzeka® 100 mg Take 1 tablet by mouth once daily Epivir-HBV® 30 25 mg Take 1 tablet by mouth once daily Vemlidy® 30 Viread® 300 mg Take 1 tablet by mouth once daily 30 Prescriber + Shipping Information Prescriber (print): __________________________________________________________ Office contact: __________________________________________ Preferred method of contact: Phone Fax Email Preferred contact persons email: ______________________________________________________ Ship to: Patient Office Alternate ________________________________________________________________________________________________ shipping address: street city state zip Office address: _____________________________________________________________________________________________________________________ (street, suite, city, state, zip) Phone: ___________________________ Fax: ______________________________ NPI: ___________________________ DEA: ________________________ Prescriber’s signature: __________________________________________________________________________________ Date: _______________________ 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. Insurance Information: Please fax copy of insurance card (front + back) 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. Updated on 9/2017
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