Hep forms 2025

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4 out of 5

59 votes

The document is a medication request form for Hepatitis C (HCV) agents from Fidelis Care, detailing the process for submitting requests for drug coverage. It includes instructions for completing the form, required patient and prescriber information, clinical criteria for approval, and necessary supporting documentation. The form emphasizes the importance of thorough completion to avoid delays and outlines follow-up requirements for continued treatment coverage.

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Click ‘Get Form’ to open the hep form in the editor.
Begin by entering the member's name, ID number, date of birth, age, height, weight, and sex in the designated fields. Ensure all information is accurate and clearly written.
Fill in the prescriber’s details including name, NPI number, contact person, address, phone number, and fax. This information is crucial for processing your request.
In the clinical experience section, select the appropriate specialty and provide details about HCV management experience. Include any collaborating provider's information if applicable.
Attach necessary supporting documents such as lab results and chart notes as specified in the checklist before submitting your form.
Review all entries for completeness and accuracy before clicking ‘Submit’ to send your completed form for processing.

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Versions	Form popularity	Fillable & printable
2015	4 Satisfied (59 Votes)

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What forms of hepatitis are there?

Hepatitis A, B, C, D, and E are each caused by a specific type of hepatitis virus. All of these viruses are contagious. Hepatitis A can be spread through contaminated food, water, or personal contact with an infected person. Hepatitis B and D spread through contact with bodily fluids such as blood or .

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