Gastroenterology Reimbursement Support Form
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1GASTROENTEROLOGY/ CROHN’S/ HEPATITIS C
REIMBURSEMENT SUPPORT FORM
Phone: (888) 601-0034
Fax: (888) 601-0049
PATIENT
Patient Name:________________________________DOB:_________________________SSN:___________________Preferred Language:__________________
Address: ________________________________________________________City:__________________________St:___________Zip:_____________________
Home Phone :(_____) _____________________Cell(______)_____________________Work Phone: (_____) __________________________________________
*****ATTACH COPY OF PRESCRIPTION INSURANCE CARD*****
PHYSICIAN
MD Name:_____________________________________________License:____________________DEA:_____________________NPI:_____________________
Address:____________________________________________________________________________________________________________________________
Phone:(______)__________________________________Fax:(______)_________________________Contact:__________________________________________
CLINICAL INFORMATION
IBD-Crohn’s-Colitis:
Date of Diagnosis_____________________
Hepatitis C
: Diagnosis: __070.54 Hep C __572.2 Hepatic Encephalopathy
Diagnosis __555.0 __555.1 __555.2
Weight (lbs):__________ Allergies:_____________________
•
•
__555.9 Crohn’s Disease NOS
HCV RNA___________IU/ml Date of Lab:_____________
•
__556.0 Ulcerative Colitis
HCV Genotype: __1a __1b __2 __3 __4 __5 __6
•
Has TB test been performed? __Yes __No Result:_____________
•
Has patient been treated for Hepatitis C? __Yes __No
•
Treatments/Duration:
Has patient had liver biopsy?
__Yes __No
•
NSAIDS_____________________________________________
If Yes, Results :______________Date of Biobsy: __________
•
Oral Corticosteroids___________________________________
Prior Failed Medications/ Duration of Treatment/Reason for D/C
•
Methotrexate_________________________________________
____________________________________________________
Sulfasalazine_________________________________________
____________________________________________________
Azathioprine_________________________________________
Xifaxan:
Does patient have cirrhosis? __yes __no
5-ASA______________________________________________
Prior drugs failed: __Cipro __Flagyl __Neomycin __Lactulose __Tetracycline
6-MP_______________________________________________
Fibrosis Scale: _________________
Biologics___________________________________________
CROHN'S /UC
HEPATITIS C
HARVONI: (Ledipasvir + Sofobuvir) 90/400 mg
CIMZIA: 200mg Vial
Induction Dose: Inject subcutaneously 400mg (2 vials) on day 1, and
Sig: 1 PO QD #28 Refills _________
At weeks 2 and 4
SOVALDI: (Sofobuvir) 400 mg
Maintenance Dose: Inject subcutaneously 400mg (2 vials) every 4
weeks
Sig: 1 PO QD #28
Reflls __________
Quantity:_________________ Refills:___________________
OLYSIO: (Simeprevir) 150 mg
REMICADE:
Sig: 1 PO QD PC #28 Refills _________
INDUCTION: IV at 5mg/kg (Dose=______mg) at 0,2, and 6 weeks
MAINTENANCE: IV at 5mg/kg (Dose=_____mg) every 8 weeks
PEGASYS PFS: (Circle Strength) 90 mg 135 mg 180 mg
OTHER___________________________________________
Quantity:____________(#of 100mg vials)
Refills:__________
Sig: ______mg SQ QWK UD #28 Refills _________
HUMIRA:
____40mg Pen
____40mg Prefilled Syringe
INDUCTION: Inject subcutaneously 160mg(4 pens) on day 1, then
PEG INTRON: Redipen 50 mg 80 mg 120 mg 150 mg
80mg (2pens) on day 15, then maintenance dosing
Sig: ______mg SQ QWK UD #28 Refills _________
MAINTENANCE: Inject 40mg (1 injection) SC every other week.
OTHER:_____________________________________________
_____________________________________________________
RIBAVIRIN: 200 mg
Quantity:____________________ Refills:___________________
Sig: ______mg POQAM, ________mg POQPM #________
SIMPONI: 100mg
MODERIBA: ___200/400 ___400/400 ___400/600 ___600/400 ___600/600
Inject 100mg subcutaneously every 4 weeks
Refills:___________________
Sig: ______mg POQAM, ________mg POQPM #________
ENTYVIO: 300 mg IVPB on Weeks 0,2,6
Refills ________
then Q8 WK's thereafter
Refills ________
XIFAXAN:
Physician’s Signature:_________________________________
550 mg
Take 1 Tablet by Mouth Twice Daily ___30 Day Supply
______________________________ _______________
Date:______________________________
Refills: __________
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.
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