VA HEPC Treatment Access Map Info

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ZAjg3PSqL4RFLJj2squbTp7XX6eI239Rei6x5HuQqPCL6xmRiQjLCASacsiLEwrT7MsHwuwBysvBA68zIRPwYgdwBA2MRpK

Virginia HEPC Treatment Access Map

A centralized resource for patients and providers to find access to treatment locations for hepatitis C including payment methods accepted, referral preference and any restrictions to ensure a positive patient experience on arrival.

Clinic Address
City
State	Zip Code
Clinic Practice Name	Email for map updates
Clinic Phone Number	Clinic Fax Number

	Clinic/ Facility Name
	Name of Person Reporting		Role of Reporter
			Other

Is hepatitis C treatment offered to patients internally at your clinic?

* must provide value

Yes

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Are you accepting new referrals at your clinic for treating patients with hepatitis C?

* must provide value

Yes

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Do you want your clinic to be listed as a resource on the Virginia HEPC Treatment Access Map?

* must provide value

Yes

We already are

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What is the best way to send referrals to your clinic?

Call with referral

Secure email

Fax

Other

Name of clinician(s) that treat hepatitis C in your clinic?

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What type of insurance(s) is accepted at your clinic?

Uninsured

Commercial

Medicaid

Medicare

Which Medicaid MCOs are accepted at your clinic?

All Medicaid MCOs are accepted

Aetna Better Health

Anthem HK

BCBS

Caremark

Humana

Magellan

Molina

Optima/ Sentara Health

United Healthcare

Virginia Premier

Other

Are any commercial insurances NOT accepted at your clinic? Please list here.

Is financial assistance offered at your clinic?

Yes

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What are the requirements for financial assistance?

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Define the terms for accepting uninsured patients (self pay, set fee or other)

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Are there restrictions for treating patients with hepatitis C at your clinic?

Yes

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What requirements and/ or restrictions are in place at your clinic? Check all that apply

* must provide value

None

Must be patient of clinic

Referral required

Clinic notes required with referral

Lab tests required prior to accepting*

Approval of clinician required prior to accepting

Sobriety*

Drug Testing*

Must live in certain geographic area*

Must be below certain income level*

Must be uninsured

Must have uncomplicated hepatitis C

Must have complicated hepatitis C, requiring a specialist*

Veteran

Please define terms of any (*) answer from above

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Please list any other restrictions in place for hepatitis C treatment not listed above

Is Office Based Addiction Treatment offered at your clinic?

Yes

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What type of OBAT is offered at your clinic?

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Are new patients for OBAT services being accepted at your clinic?

Yes

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Has anyone completed the Virginia HEPC Clinician and Support Staff Training from your clinic?

Yes

No, but I am interested in learning more

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Is anyone in your clinic a part of the Virginia HEPC Community of Practice?
(Virtual continuing education on hepatitis C, the 3rd Wednesday of each month from 4 pm- 5 pm)

Yes

No, but I am interested in learning more

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Any additional information you would like to add

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Thank you for your time in filling this out. The information will enable patients across the state to access treatment. Please reach out with any changes to the information you have provided or with any questions. hepc@sentara.com 434-235-0139

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